Psychoanalytic approach to eating disorders

Apr 15

Written By Nikki Venere Brenner

A Dissertation.

PSYCHOANALYTIC PERSPECTIVE ON EATING DISORDER TREATMENT: A QUALITATIVE INQUIRY

Nikki Venere Brenner

AMY DONOVAN, PhD, Faculty Mentor and Chair JA’NET HOWARD, PhD, Committee Member NATALIE MARR, PhD, Committee Member

Joshua L. Stanley, EdD, Dean School of Social and Behavioral Sciences

A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree Doctor of Psychology

Capella University March, 2022

Abstract

This generic qualitative study focused primarily on the psychoanalyst’s perspective on eating disorder treatment, particularly anorexia nervosa (AN) and bulimia nervosa (BN). Psychoanalysts were interviewed to gain an understanding as to what the psychoanalytic treatment would entail for patients, and what it is like treating anorexia and bulimia patients. Data obtained from the interview process unveiled three significant themes concerning relationships, emotional distress, and the gaps within treatment. The findings suggested that eating disorder (ED) treatment fundamentally involves a more in-depth exploration of the individual’s psyche, rather than solely focusing on the patient’s symptoms.

Dedication

To my loving and caring husband Shawn who has been in my corner for 16 years. Your belief in me has fueled my ambition. Your support motivated and encouraged me to help others. Your love, which knows no bounds, helped to give me the confidence I needed to embark on a difficult and rewarding journey. Not only have you blessed me with the opportunity to achieve my goal as a future clinical psychologist, but during this doctoral adventure you blessed me with a beautiful baby boy. DeAngelo and I are so lucky to have you in our lives. We cannot express to you the immense love we have for you. Thank you to the best husband and father.

I want to take this opportunity to thank my parents, Nick and Angie, who have given me the tools needed to progress in a competitive and demanding field. I am a fighter and a healer because of how I was parented, and I cannot thank you both enough for teaching me to be humble, kind, and inquisitive. I would like to thank my sister Victoria for helping me to stay motivated, and I am more than grateful for your positive affirmations. I also want to thank my brother Nikolas for helping me see the humour life has to offer, and not to take life so seriously.

I want to thank my mentor Dr. Amy Donavon, who has been my rock, research expert, and provided a shoulder when I was in need. I cannot thank you enough for always being there for me when I need you, and giving me hope when I thought there was not any. Without your help I would have been lost embarking on this research journey.

Finally, I would like to thank the seven participants who graciously set aside time during their busy day to meet and converse with me. It was such a pleasure to meet each participant. I have learned a lot from every person, and I am glad to say I have made new professional relationships. Thank you kindly for your precious time and wisdom.

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Acknowledgments

My heart extends to those who are struggling with an eating disorder, whether that be anorexia, bulimia, binge eating, or problematic eating patterns. It is a difficult ride for both the individual and their loved ones. I want to acknowledge whole heartedly those who struggle yet feel they do not have a voice. Hopefully this research paper is a start in helping both the research and clinical community comprehend what it means for individuals to struggle with an eating disorder, as well as advocate for long-term treatment.

Table of Contents

Acknowledgments iv CHAPTER 1. INTRODUCTION 1 Background of the Problem 1 Statement of the Problem 4 Purpose of the Study 6 Significance of the Study 7 Research Question 10 Definition of Terms 12 Research Design 15 Assumptions 16 Expected Findings 18 Organization of the Remainder of the Study 19

CHAPTER 2. LITERATURE REVIEW Introduction to the Literature Review Theoretical Orientation for the Study

Drive Theory

Defence Mechanism

Structural Model

Object Relations

Self Psychology

Contemporary Relational Movement Lacanian Psychoanalysis

Review of Research Literature CBT and Psychoanalysis Psychoanalytic Diagnosis Biological Implications Psychological Implications Social Implications Trauma

Parenting Style

Treatment Recommendation Methodology Review

Synthesis of the Research Findings Critique of the Previous Research Summary

CHAPTER 3. METHODOLOGY Purpose of the Study

Research Question Research Design Target Population Procedures Instruments

Data Analysis

Ethical and Other Considerations Summary

CHAPTER 4. RESULTS

Introduction: The Study and the Researcher 75 Description of the Sample 76 Research Methodology Applied to the Data Analysis 77 Presentation of the Data and Results of the Analysis 79

Theme 1: Relationships 79 Theme 2: Emotional Distress 84 Theme 3: Treatment Limitations 88

Summary 90 CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS 91 Summary of the Results 91 Interpretation and Discussion of the Results 93

Theme 1: Relationships

Theme 2: Emotional Distress Theme 3: Treatment Limitations

Discussion of the Conclusions Limitations

Recommendations for Future Research Conclusion

REFERENCES

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CHAPTER 1. INTRODUCTION Background of the Problem

Societal and cultural perceptions of beauty can have a debilitating impact on how individuals think and feel about their body. Marketing industries have targeted young adolescent males and females- including but not limited to fashion magazines, clothing stores, car dealerships, and alcohol sales-reinforcing the notion that a “thin hot body” is associated with an upper-class lifestyle, happiness, freedom, meaningful relationships, and an overall strong sense of self. Chang (2020) found there was a strong association between global self-esteem and the drive for thinness. But what would happen if the body was no longer thin? For some people the thought of gaining weight is incumbering, which can elicit masochistic intrusive thoughts and behaviours such as the desperate need to induce vomiting (Change, 2020; Hilsenroth et al., 2018).

For some people the fear of gaining weight is so intense they begin to restrict their food intake leading to a significant reduction in weight, which is known as anorexia nervosa (AN). According to the Diagnostic Statistical Manual 5th Edition (DSM-5), the diagnostic criteria for AN includes restricting food in order to lose weight, an intense and irrational fear of gaining weight, and a disturbance in the individual’s perception pertaining to how they view their body (American Psychiatric Association, 2013). Wooldridge (2017b) argued from a psychoanalytical perspective, suggesting that restricting behaviours are reportedly associated with a devastating and psychotic terror of “being fat.” The terror is said to be caused by the over identification of a

parent (or parents) who have reinforced an unconscious association between food and the fear of gaining weight (Wilson, 1988). It can be argued that restricting, or avoidant behaviours can be a representation of an attack on the psyche by way of unconscious guilt (Carveth, 2001; Wilson, 1988). For example, an individual may internalize food cravings as an unconscious representation of their failures, and thus attack their psyche as a consequence for their shortcomings. Fundamentally, individuals struggling with AN experience an intense “fat phobia”, otherwise known as obesophobia, which can spark the compulsive need to restrict one’s food intake to reduce the possibility of gaining weight.

Others may binge and purge to reduce intrusive thoughts associated with the fear of gaining weight. DSM-5 criteria suggest that a diagnosis of bulimia nervosa (BN) is contingent on these factors: recurrent episodes of eating copious amounts of food in a short period of time, feel a lack of control over cravings and/or how much food one ingests, feelings of shame along with the fear of gaining weight ignite compensatory behaviours to prevent weight gain such as vomiting or the use of laxatives, and a negative self-evaluation of one’s body image (American Psychiatric Association, 2013). Wooldridge (2017b) and Schwartz (1986) conceptualized BN cases analytically, proposing that the patient’s development was hindered by a narcissistic unavailable mother, and/or by an overstimulating seductive father. The uncontrollable ingestion of food, and the compulsive need to use one’s finger to penetrate the throat resulting in a vomit eruption, symbolizes the over identification of both parents (Schwartz, 1986; Wooldridge, 2017b). There is also evidence to suggest that the patient, by way of vomiting, is actively attempting to rid the mind of some sexualized trauma (Wooldridge, 2017b). Defence mechanisms such as denial and repression allow for the trauma to stay buried in the unconscious, resulting in the manifestation of psychological symptoms including maladaptive behaviours.

According to psychoanalytic theory elements of the trauma attempt to breach the conscious mind, which patients refer to as intrusive thoughts, nightmares, and/or flashbacks (McWilliams, 2004). Since the conscious part of the psyche cannot adequately process the trauma the BN individual then uses defence mechanisms, such as denial and repression, to protect their psyche against the trauma. This is an unsuccessful attempt because the cycle then continues, where the repressed trauma yet again surfaces by way of intrusive thoughts, negative feelings, and compensatory behaviours.

In conceptualizing AN and BN cases psychoanalytically, it is suggested that majority of individuals have experienced some form of trauma, including but not limited to sexual abuse, before the onset of puberty (Lingiardi & McWilliams, 2017). The trauma has then created a ripple effect impacting the individual biologically, psychologically, and socially, resulting in the establishment of poor attachments with the self and others. These insecure attachments, established early in life, can unfortunately pave the way for insecure interpersonal and intrapersonal attachments in adolescence and adulthood.

This study predominately focuses on the relationship between the psychoanalyst and patient insofar as to explore what can happen within the AN and BN psychoanalytic treatment. Particularly, the study centers on the psychoanalyst’s overall experience. According to the National Initiative for Eating Disorders (NIED) (2020) there are approximately one million people in Canada diagnosed with an eating disorder (ED). NIED (2020) also revealed that Canada has the highest ED mortality rate between 10-15%, where 20% of AN individuals die by suicide, and 25-35% of AN and BN individuals attempt suicide in their lifetime. There are many medical and clinical perspectives that aim to treat AN and BN, including but not limited to pharmacology, psychotherapy, family therapy, and education concerning the body and nutrition,

which will be outlined in Chapter 2. Even though there are several valuable resources available to AN and BN individuals it is argued that psychotropic medication, family therapy, and education concerning the body and nutrition are advantageous adjuncts to psychoanalytic psychotherapy (Wooldridge, 2017b). Furthermore, some would argue that psychoanalysis is the only treatment that digs deep into the psyche, allowing the patient to unveil their core fantasies about food, what eating represents, and reveal the trauma that the mind has hidden from itself (Wooldridge, 2017b).

Statement of the Problem

The typical evidence-based treatment involves focusing on reducing the impact of AN and BN symptoms. For instance, cognitive behavioural therapy (CBT) aims to conceptualize AN and BN insofar as to deconstruct one’s intrusive thought process by identifying and understanding their negative core beliefs (Dryden & Branch, 2011). Identifying maladaptive thought patters- as well as the use of coping strategies and other behavioural techniques- does not fully suffice as an adequate treatment for the AN and BN population (Haverkampf, 2017; McWilliams, 2004). With regards to CBT treatment, progress is then measured by way of observing the reduction in maladaptive behaviours. The pragmatic and standardized CBT approach to psychological treatment does not account for the unconscious driving factors behind the AN and BN patient’s symptomatology, and the ways in which these underlying factors can affect daily functioning.

The psychoanalytic relationship between the psychoanalyst and patient is based on a foundation of trust, genuineness, and openness, which allows both the patient and psychoanalyst to speak their mind (McWilliams, 2021). Additionally, the psychoanalytic relationship is an equal partnership that requires both the psychoanalyst and patient to actively identify

associations, address what is occurring with the transference and countertransference, as well as analyze and process interpretations. As an example, the psychoanalyst may relay an interpretation suggesting that the patient’s restricting behaviours are a representation of their unconscious guilt, where the patient’s unconscious guilt can induce an unconscious attack on the self. This is done by way of restricting the basic necessity of food in order to ongoingly punish the self for some terrible crime. Using defence mechanisms, such as repression and denial, AN and BN individuals may continue to unconsciously attack the self. This attack begins with negative self-talk-such as “I am not good enough”, “I am too much for people”, “No one cares about me”- and then is acted out behaviourally in the form of restricting, binging, and/or purging (McWilliams, 2004). By establishing a “friendly” and professional relationship, while simultaneously providing an enriched psychoanalytic interpretation of the driving factors behind the patient’s symptoms, allows for the progression in treatment. This approach is slightly different from the traditional psychoanalytic method where Sigmund Freud argued that the psychoanalyst should remain “neutral”, to allow the patient to project onto the psychoanalyst (McWilliams, 2004). According to traditional psychoanalysts, remaining neutral involves becoming a blank canvas for the patient to draw upon, which may include limited conversation and expression within session (McWilliams, 2004). The traditional psychoanalytic approach may not serve AN and BN patients well since the environment may be perceived as cold. Without the foundation of a strong relationship and the richness of psychoanalytic treatment, AN and BN individuals will ultimately continue to act out their repressed trauma (Wooldridge, 2017b).

All in all, there are limitations to CBT as a treatment for AN and BN, which will be addressed in Chapter 2. Therefore, psychoanalytic psychotherapy aids in providing a more enriched treatment that focuses on the underlying factors that drive one’s ED. The

psychoanalyst’s perspective and experience in treating AN and BN will be explored in more detail. The interview process, in particular, aids in exploring the psychoanalyst’s perspective concerning ED treatment, experience treating AN and BN patients using psychoanalytic psychotherapy, as well as explore the psychoanalytical relationship as a fundamental component of the analytical treatment.

Purpose of the Study

The purpose of the study was to explore the psychoanalyst’s treatment perspective and experience working with patients diagnosed with AN and/or BN. In other words, this study intended to explore the perspective and experience of the psychoanalyst to gain a clear understanding of what it means to treat AN and BN patients. The overall study aimed to paint a sharper picture of AN and BN from a psychoanalytic perspective and to explore the fundamentals of treatment, which involves building secure and healthy attachments. Exploring the psychoanalytic perspective, in this case, pertained to the investigation of the psychoanalyst’s experience in hopes of: a) gaining an understand of the psychoanalytic relationship, as well as b) comprehend the ways in which the psychoanalytic relationship can aid in the analytic treatment process. As such, it was important to explore whether the psychoanalytic relationship and/or analytic treatment approach assisted in the AN and BN patient’s progress.

The exploration process involved comprehending what occurred within the transference between the psychoanalyst and patient, discuss the psychoanalyst’s countertransference, as well as investigate the psychoanalytic relationship dynamic as a helper or hinder pertaining to the patient’s progress. Psychoanalytic treatment is not a popular treatment, in the sense that not many therapists are trained in treating a person’s unconscious psyche even though the treatment generates positive long-term results (de Matt et al., 2009). In addition to analyzing the elements

of psychoanalytic treatment, it is with hope this study spreads awareness about psychoanalytic treatment as an advantageous treatment modality, aid in understanding the psychoanalyst’s countertransference as a valuable part of the treatment, as well as be open to the power of the psychoanalytic relationship as an expression of a healthy and secure attachment. Overall, this psychoanalytic investigative study will expand upon prior psychoanalytic research, include more modern psychoanalytic perspectives, as well as provide some insight into the practical application of psychoanalysis.

Significance of the Study

There is a substantial need for this study. Therapeutic orientations, including but not limited to CBT, are considered empirically based. Block (2016) outlined that the CBT approach involved identifying one’s core belief and associative maladaptive thoughts, whereas the behavioural approach incorporates the use of techniques such as coping strategies to help improve functionality. CBT does not attempt to understand the unconscious mind as a means to explore what other factors may be driving an individual’s behaviour. As such when it comes to ED treatment, it is argued that CBT therapists and patients fall victim to an enactment, where the use of techniques and coping strategies can help strengthen the denial and repression defences (Marmor, 2018). It is theorized that individuals act in accordance with the unconscious part of the mind, this is what accounts for why individuals who know how to improve their functionality remain stuck (Marmor, 2018). If this is the case, then it is within the psychoanalyst’s best practice to analyze the depths of the unconscious mind. This process includes assessing resistance, including but not limited to one’s defence mechanisms, as well as provide interpretations to aid the patient in building insight into the relationship with the self and others (Marmor, 2018; McWilliams, 2004). The more the patient understands their mind and processes

their unconscious thoughts, feelings, and experiences, their psyche and core personality alters in such a way as to foster healthy behaviours (Bohleber, 2018).

AN and BN treatment require a more in depth, intensive, and long-term specialized treatment. By allowing individuals to explore their mind, through free association, the unconscious begins to surface, which then is analyze and treated systematically within the transference (McWilliams, 2004). Getting to the root issues of an individual’s complex psyche is difficult and exhausting. Complex core fantasies that are unconscious to the AN and BN patient must be brought to the surface, elaborated upon, and processed, otherwise the body can hold onto the psychic trauma (Wooldridge, 2017b). This process can take years and can impact the psychoanalyst in a variety of ways, including holding resentment within their countertransference, experience a reduction in empathetic understanding and listening, and/or feeling depleted of their psychic energy (Levin, 2019). Therefore, it is also important to understand the psychoanalyst’s experience in working with AN and BN patients. This is achieved by identifying and comprehending the psychoanalyst’s role in session, as well as their thoughts, feelings, and experiences that surface during sessions with AN and BN patients.

The psychoanalytic theory motivating this study suggests that our behaviours are fuelled by unconscious drives, such as pain and desire (Leonardi et al., 2021). The practical application of this psychoanalytic theory allows for the exploration of the many parts of the psyche, including free association. This is significant because complex AN and BN cases require more than just a theory to support their treatment. Unlike the CBT approach, the psychoanalyst does not establish an agenda, nor provides patients with homework outside of session. Everything is analyzed within the session. Brisman (2017) argued that what happens within the session, within the transference, can also arise outside of session. For instance, if the patient dissociates during

session - such as not paying attention or frequently forgetting what they were going to say - the individual may also dissociate outside of session with others. Brisman (2017) outlined the significance of treating ED patients using analytical interpretations to help build the patient’s insight about the part of them that dissociates. It is argued that during childhood or adolescent development a particular trauma occurred that induced a split within the psyche, and the individual become dissociated from the self and the world; otherwise known as depersonalization and derealization (American Psychiatric Association, 2013; Brisman, 2017; Wooldridge, 2017a). The psychoanalyst’s role is to use therapeutic techniques- such as summarizing, paraphrasing, and reflecting - in order to explore the part of the psyche that is traumatized. Once there is significant elaboration the psychoanalyst will then provide an interpretation, and both the psychoanalyst and patient can brainstorm together to dig deeper into the complexities of the mind (McWilliams, 2004). Peeling back the layers of trauma, bringing the trauma to the surface, and ultimately processing the pain is the most effective treatment modality for AN and BN patients (Brisman, 2017). However, this process is a long-term process, and can be exhausting for both the psychoanalyst and patient. Therefore, it is important for both the psychoanalyst and patient to be mindful of what is occurring within the transference and countertransference. It is especially important for the psychoanalyst to be able to contain the parts of the patient that are projected onto the psychoanalyst, as a means to maintain stability within the treatment. In other words, it is vital for the psychoanalyst to remain free from judgment, be open-minded, and avoid personalizing the patient’s aggression. Containing the anger allowed the patient to freely express their anger, without the psychoanalyst internalizing the anger as something that is theirs and not the patient’s. In other words, it is the responsibility of the psychoanalyst to contain the patient’s anger insofar as to be able to provide insightful interpretations that incorporate what the patient’s

anger represents. As an example, the patient may exhibit unconscious rage towards their mother, and thus unintentionally project the rage onto the psychoanalyst in the transference. Psychoanalysts, due to their specialized training, are able to contain both their mind and the patient’s mind. Therefore, there is evidence to suggest that the psychoanalyst, rather than the CBT therapist, is able maintain homeostasis through the process of containment when the AN or BN patient becomes enraged. By capturing the dynamics between the psychoanalyst and patient - especially complex cases such as AN and BN - can aid in a better understanding of AN and BN, as well as what it means to have a relationship with the self and others (Wooldridge, 2017a).

Research Question

The mind of a psychoanalyst is not often explored, especially with regards to the psychoanalyst’s experience treating complex mental illnesses such as AN and BN. It is curious to know what happens to a psychoanalyst when they treat AN and BN cases, and how they manage what comes up for them in their countertransference. These curiosities and more led to the exploration of the psychoanalysts’ mind. The research question explored in this qualitative study is, how would psychoanalysts describe their experience providing psychoanalytic treatment to AN and BN patients?

AN and BN are multifaceted mental disorders that can be very tedious to treat (Wooldridge, 2017a). The masochistic behavioural patterns portrayed by individuals struggling with AN and BN - including but not limited to intentional starvation and self-induced vomiting - are complex multilayered disturbances that require long-term specialized treatment (Levin, 2019; Wooldridge, 2017b). The DSM-5 categorizes AN in terms of restricting behaviours and/or excessive exercising (American Psychiatric Association, 2013). Additionally, symptoms such as mood disturbances, substance dependency, and impulsivity can also arise. Individuals with BN

not only experience compensatory behaviours but may also struggle with mood instability, anxiety, and obsessive tendencies (Schaumber et al., 2020; Vidaña et al., 2020). AN and BN are complex and cyclical mental disorders that can hinder one’s functionality for years if not treated properly (Wooldridge, 2017a).

It is suggested that insights into the psychoanalyst’s mind will help to unveil the elements of the psychoanalytic relationship between the psychoanalyst and AN and BN patient. The psychoanalytic relationship is significant because this helps to establish trust, which then allows for a foundation of insight to build upon (McWilliams 2004; McWilliams 2011). Trust goes both ways. The patient must trust the psychoanalyst insofar as to freely express who they are and how they feel, free from judgment, and without the fear they will destroy the psychoanalytic relationship. The psychoanalyst must also establish a sense of trust. Trust that the patient can think independently and is able to express their distress in session, trust in their countertransference, and trust in their analytical training. It can be argued that maintaining balance in the psychoanalytic relationship, especially during intense and stressful sessions, can allow for growth. Psychoanalysis is a beneficial treatment for AN and BN individuals because the unconscious mind can process the psychic trauma so patients no longer have to act out their emotional distress (Wooldridge, 2017b). This process is done by analyzing what is being presented in the transference, and to what extent the psychoanalyst can contain the distress in the transference to effectively provide their observations and interpretations. The result entails guiding the AN and BN patient in rebuilding the self, with the added insight, to establish a secure attachment with the self and with others.

Definition of Terms

This section contains definitions that were used in this paper.

Acting Out: refers to the unconscious maladaptive behaviours, such as restricting, binging, and purging, to express the AN and BN patient’s internalized thoughts, feelings, and experiences. In this case, the AN and BN patient is unable to articulate their self, thus they are unconsciously driven to act out their psychic trauma.

Anorexia Nervosa: refers to a psychiatric condition as outlined by the DSM-5, which is marked by restricting one’s food intake as a means to lose weight (American Psychiatric Association, 2013).

Bulimia Nervosa: refers to a psychiatric condition as outlined by the DSM-5, which is categorized by maladaptive behaviours including binging and purging as a means to lose weight (American Psychiatric Association, 2013).

Cognitive behavioural therapy (CBT): a form of talk therapy where the clinician focuses on the individual’s thought patterns and behaviours (David et al., 2018). It is suggested that by re-structuring one’s conscious maladaptive thoughts the individual will then possess the capacity to behave in a different manner, which is more conducive to their overall health (David et al., 2018).

Containment: refers to a process where an individual, the psychoanalyst or patient, can hold two opposing concepts in the mind. Part of the psychoanalyst’s role is to act as the container, to maintain the patient’s aggression, sadness, and/or fear as well as the their own (Steiner, 2000).

Countertransference: similar to the notion of transference, countertransference refers to the psychoanalyst projecting their internalized objects, distress, or emotions within the session.

Most psychoanalysts use their countertransference, what they sense within session, as a means to guide the session (McWilliams, 2011).

Enactment: involves the AN and BN patient “acting out” of various thoughts, feelings and/or experiences (Steiner, 2000). An enactment manifests when the psychoanalyst unconsciously allows their countertransference to take over, which then unintentionally aids in the maintenance of the AN and BN patient’s denial. The unintentional safeguarding of defence mechanisms like denial ensures that the AN and BN patient’s thoughts, feelings, and traumatic experiences remain stuck in the psyche, rather than therapeutically expressed, and processed.

Free association: a technique used in psychoanalytic treatment. Free association allows the patient to think and talk about whatever pops into their mind, without will, without force. Just simply allow the thoughts to surface. The theory was that the more one would freely talk the more in which the unconscious mind became accessible (McWilliams, 2004: McWilliams, 2011).

Frame: the frame can be thought of as a kind of structure, a set of boundaries, that helps guide the psychoanalytic treatment to avoid anarchy (Tylim & Harris, 2017). Elements of the frame can include, but are not limited to the date, time, location, cost per session, and any communication inside and outside sessions (Tylim & Harris, 2017).

Interpersonal relationship: Refers to the social involvement and connection between two or more people (Holt, 1970).

Intrapersonal relationship: Refers to feeling connected to oneself, one’s thoughts, feelings, and personality (Holt, 1970).

Obesophobia: refers to the debilitating fear of gaining weight, or “being fat” (Robertson, 2003; Tokumitsu et al., 2016).

Personality structure: personality is composed of many different parts, including but not limited to: defence mechanisms, attachment style, and past childhood experiences (McWilliams, 2004). Rather than looking specifically at the individual’s symptoms, psychoanalysts treat the AN and BN personality structure.

Psyche: refers to the specific forces, drives, or energy that can significantly impact one’s thoughts, feelings, and behaviours (Elder, 2019).

Psychic Trauma: an emotionally and psychologically disturbing experience that sparks a disruption in the psyche, which can negatively impact one’s thoughts, feelings, and experiences (McWilliams, 2011). A psychic trauma may also include a traumatic experience, as outlined by the DSM-5.

Psychoanalysis: otherwise referred to as psychoanalytic treatment, incorporates both psychoanalytic psychotherapy, psychodynamic psychotherapy, as well as the traditional Freudian approach of psychoanalysis. Freud encouraged psychoanalysts to facilitate introspective therapy sessions five to six times a week, as a means to effectively access the unconscious mind (McWilliams, 2004). The traditional approach can sometimes be overwhelming for patients. Therefore, over the years flexible approaches have surfaced including psychodynamic psychotherapy, which is a less intense and rigorous version of traditional psychoanalysis.

Psychoanalyst: a “psychoanalyst” is a title given to individuals who have completed the necessary training, and are associated with organizations such as the TPS&I. In the context of this study, a psychoanalyst is someone who holds the title of psychoanalyst, someone who uses psychoanalytic/psychodynamic psychotherapy, as well as someone who is completing their psychoanalytic training.

Psychoanalytic Relationship: psychoanalytic relationship is an enhanced version of the therapeutic alliance, insofar as a connection is made on a deeper level. Psychoanalytic techniques - such as free association and empathy - are used to help create a safe space to freely express any and every thought, feeling and experience, both the AN and BN patient as well as the psychoanalyst.

Transference: this is a phenomenon that occurs within a therapeutic session where the patient unconsciously projects their internalized objects, such as a loved one, onto the psychoanalyst (McWilliams, 2011).

Research Design

As stipulated, the aim of the study was to comprehend the psychoanalyst’s experience treating those diagnosed with AN and BN. This is done by exploring the psychoanalyst’s experience within the session, investigate the psychoanalysts’ mind as they reflect upon their past ED sessions, as well as examine the relationship between the psychoanalyst and patient.

This generic qualitative study will explore and expand upon psychoanalytic theory, and the psychoanalyst’s experience. Data was collected via interviewing psychoanalysts, or psychoanalysts in training, who have worked with individuals diagnosed with AN and/or BN. The sample population will also include those licensed as a clinical psychologist or registered psychotherapist in Ontario, Canada. Seven participants were asked to partake in an interview that was conducted virtually, either by telephone or video. Participants were recruited from databases from the Toronto Psychoanalytic Society and Institute (TPS&I) and the Toronto Institute for Contemporary Psychoanalysis (TICP). Those who choose to volunteer were informed of the parameters of the study and provided with a consent form (College of Psychologists of Ontario, 2021). Participants were not given the interview questions in advance since the aim was to

capture an authentic response to the questions and allow for the psychoanalyst to freely associate during the interview. Virtual interviews will be audio recorded as outlined in the participant consent form. As required by the College of Psychologists of Ontario (CPO), confidentiality was maintained insofar as no identifiable information was shared with a third party (College of Psychologists of Ontario, 2021). Data security was also a top priory. Thus, information extracted from the interview process was stored on an encrypted USB to comply with the research regulations outlined by the CPO (College of Psychologists of Ontario, 2021). The raw data obtained from the audio recordings was then be transcribed in order to complete a thematic analysis. More information about the interview process and data collection will be outlined in Chapter 3 and Chapter 4.

Assumptions

Topic-Specific Assumptions

It is evident that assumptions are a primary component of the qualitative design process (Apuke, 2017). The topic of the study includes an investigative and analytical exploration of the psychoanalyst’s experience in treating AN and BN patients. Ontology focuses fundamentally on the study of “being”, which many philosophers and psychologists have explored. It is important to address the ontological assumptions within the study since this research focuses on the psychoanalyst’s experience and psychoanalytic perspective. Since participants articulated their subjective experiences during the interview process there was no “absolute truth”, rather truth is deemed relative. More specifically, the ontological assumption can be associated with the notion of positivism, which suggests that the concept of absolute truth is idealistic since reality is not perfect nor standardized (Höijer, 2008). The generic qualitative design allows for participants to freely associate during the interview to explore their thoughts, feelings, and experiences treating

AN and BN patients. Even though the interview questions are semi-structured participants are able to freely discuss what is on their mind, allowing participants to elaborate as needed. Theoretical Assumptions

Firstly, it is important to note that the theoretical foundation for this study is psychoanalytic in nature. Having that said, the framework, methodological approach, and interpretations are all based on the psychoanalytic perspective, which encompasses a wide range of psychoanalytic theories. Some people share similar analytical views. However, it is assumed that majority of clinicians do not understand and/or agree with the psychoanalytic approach to treating mental illness. Nevertheless, the fundamental goal for this study is to present the information obtained during the interview process.

The interview process was semi-structured where participants could not partake in free association in its traditional form. Even though participants could not engage in the conventional technique of free association, the semi-structure questions allowed participants to semi-freely associate and discuss what was on their mind. Lacan believed that it was difficult for one person to fully comprehend the mind of another person (Alparone & La Rosa, 2020). In other words, the process of communication between two or more people becomes quite complex, especially when individuals cannot accurately articulate what is on their mind and/or their message is misinterpreted by others. There is a linguistic assumption, which refers to how accurately participants can articulate what is on their mind, and to what extent can the message be understood and interpreted accurately. Therefore, it is important to treat the interview like therapy session, and use therapeutic techniques such as summarizing, to verify if what was inferred was actually implied by the participant.

Methodological Assumptions

A generic qualitative design was used to conduct a thematic analysis in order to explore the depths of the psychoanalyst’s mind regarding their experience treating AN and BN patients. Qualitative research involves the process of obtaining detailed information by way of investigating a phenomenon in more detail, using an accepted scientific and standardized approach (Kostere & Kostere, 2021). A general assumption had to do with the notion that a semi- structured interview, which included seven open-ended questions, would be sufficient in capturing the psychoanalyst’s experience treating AN and BN patients. It was also assumed that all participants were honest and forthcoming pertaining to their history of treatment with AN and BN patients. There is no way to verify if participants were honest about their professional experiences. Therefore, it was assumed that what participants were saying was the truth.

With all of that said, it is important to note that causality was not inferred since this study is based on a qualitative design, not a quantitative research study. As such, generalizability is not significant. What is significant is attempting to accurately comprehend and present the psychoanalyst’s experience and relationship with the AN and BN patient.

Expected Findings

For this study there are no expected findings. The goal involved exploring the psychoanalyst’s perspective and experience treating AN and BN patients. Interviews took the form of a psychoanalytical session. During the interview process participants engaged in free association, and I approached the interview with no agenda. Wilfred Bion addressed the importance of allowing patients to think “unthought thoughts” (Symington & Symington, 2002). Specifically, he argued that the way in which an individual can remain on the road to recovery is by tolerating self-doubt and intimacy with the unfamiliar (Symington & Symington, 2002). The

interview dynamic is unfamiliar territory that can also elicit self-doubt. Simply allow the interview to happen and see what would manifest.

The interview can also be assessed by way of focusing the transference and countertransference dynamic. In other words, it is important to note that certain dynamics within the interview can also induce particular thoughts, feelings, and experiences within the researcher. Identifying what was being internalized, with regards to the interview, may also give way to insightful information concerning the dynamic between the AN and BN patient and psychoanalyst. As stipulated, interpersonal and intrapersonal dynamics that occur within the session is most likely, if not guaranteed, to occur outside of the session (McWilliams, 2004). For instance, if the patient perceives the psychoanalyst’s silence as a form of hostility and disappointment, then it is most likely this is also projected at work onto a boss and/or at school onto a teacher. The patient’s projection of hostility could also induce something in the psychoanalyst. If this is the case, whether the psychoanalyst is conscious or unconscious of this enactment, the participant may also bring that hostility to the interview.

Organization of the Remainder of the Study

The research methodology and overall process was structured and detailed, to satisfy the research requirements of the CPO and Capella University. Before beginning the study, I completed a dissertation proposal that was then approved by the Institutional Review Board (IRB) at Capella University, which included but was not limited to: a detailed consent form, specific accounts regarding how one’s private information was stored, the process by which data was collected, as well as a detailed account of the recruitment process. This information will be addressed in more detail in Chapter 3.

The interview process was semi-structured that focused on the psychoanalyst’s perspective treating AN and BN patients, as well as explore what happened to the psychoanalyst within the treatment. The interview questions were constructed in an open-ended and general fashion in order for participants to let their mind wonder. Aside from the focus of the study, there was no agenda while facilitating the interview, which allowed the participant to talk about whatever came to mind about their AN and BN patients. The psychoanalytic approach, with regards to the interview process, elicited enriched data that captured the essence of psychoanalysis as well as the psychoanalytic relationship. Specific information about the interview process will be discussed in Chapter 3 and Chapter 4.

Data collection, transcribing, and interpreting the data was completed in a systematic fashion, satisfying the research requirements of the CPO and Capella University. Interviews were audio recorded and then transcribed in order to complete a thematic analysis. More information about data collection and the results of the thematic analysis will be discussed in Chapter 4 and Chapter 5.

CHAPTER 2. LITERATURE REVIEW Introduction to the Literature Review

The central components of Chapter 2 fundamentally address the literature review pertaining to the research topic, address the theoretical factors that contribute to AN and BN, treatment recommendations, and an evaluation of the literature. The literature was found using the Capella Library, and PEP Web.

Theoretical Orientation for the Study

Drive Theory

Sigmund Freud’s original theory of personality focused on the physiological aspects of development, arguing in favour of the biological drive theory. Freud’s biological drive theory fundamentally addressed that instinctual and animalistic processes, along with the constructed self, passed through specific stages overcoming obstacles at each stage (McWilliams, 2011). Freud theorized that the individual learned about the self, and how to survive by way of the sensations and conflicts experienced during the psychosexual stages of development.

Oral Stage

Freud elaborated on his psychosexual stages of development suggesting that infants from birth to one year seek pleasure orally, what he labelled as the oral stage (Rennison, 2015). Infants at this stage interact primarily with their mouth – sucking, biting, licking, drooling, talking, and laughing – through the gratification of food, soothers, and interactions with their caregiver (Rennison, 2015; Knight, 2017). The infant begins to build a trusting relationship with those who provide the infant with such oral pleasures. Freud identified that the primary conflict at the oral stage involved establishing a balance between being dependent upon the caregiver, and the

ability to self-soothe (Rennison, 2015). Freud argued that if children were overstimulated or overly frustrated this would create a fixation at the oral stage (Rennison, 2015). It can be theorized that AN and BN individuals are stuck at the oral stage of development, trying to manage conflicts between dependency and independence, overindulgence, and restraint. Anal Stage

The second stage of development is the anal stage, which begins around ages one to three. The anal stage marks the emergence of the libido through governing bodily sensations, such as the bladder and bowel movements (McWilliams, 2011). In other words, the child begins to learn there is a sense of pleasure in controlling one’s ability to urinate or defecate. Crucial conflicts at the anal stage pertains to the strenuous and debilitating task of toilet training (Rennison, 2015). Parenting styles are contingent on the manner in which the child progresses through the anal stage. For instance, if caregivers are too laidback this may result in an “anal- expulsive personality” in adulthood, where the individual is more likely to be disorganized, destructive, and/or wasteful (Guido et al., 2018). In opposition, caregivers who were too strict in their toilet training resulted in an “anal-retentive personality”, whereas the adult’s disposition centered on a more rigorous, unyielding, obsessive, and methodical personality construct (Guido et al., 2018). It is not illogical to suggest BN individuals may have struggled at the anal stage, resulting in an anal-expulsive personality. Disorganization and chaotic traits associated with binging may be desperately masked by the wish for control, induced by vomiting and/or defecating, which is an unconscious way to dump and rid the body of what is thought to be toxic. Phallic Stage

The phallic stage begins around the ages of three to six and is marked by the child’s discovery of their genitals, and their expanding awareness of the distinctions between females

and males (Guido et al., 2018). Freud thought male children began to perceive their father as an unconscious threat, and thus fought for their mother’s attention and affection, which was labelled as the Oedipus complex (Guido et al., 2018). Even though the child unconsciously wants to overthrow the father the child is also fearful he will be severely punished by the father, the alpha male, what Freud identified as “castration anxiety” (Guido et al., 2018). Additionally, Freud argued that females experienced penis envy, and thus females were driven by their sexual and reproductive urges (Morss, 2020). He continued to argue that the primary conflict for females, at the phallic stage, had to do with the understanding they are inferior to males and thus continue to desire the power of the penis (Morss, 2020). Carl Jung elaborated by arguing that females, like males, will unconsciously fight for the admiration and attention of the father, what he addressed as the Electra complex (Morss, 2020). One limitation associated pertaining to the phallic stage is that the traditional theory did not account for developmental factors associated with homosexuality or asexuality. Freudian and Jungian theories were developed during a time where heterosexual relationships dominated socially acceptable worldviews, where males were perceived as superior compared to females.

Latent Stage

The latent stage emerges between the ages of six and about thirteen years old. Freud highlighted individuals at this stage begin to develop their ego and superego, thus their sexual id derives become inhibited (Guido et al., 2018). At this impressionable age individuals begin to cultivate their self-concept by interacting with peers, influenced by advertising campaigns and social media, taught to abide by social and cultural traditions, as well as continue to develop their psyche. It is argued that a fixation at the latent stage of development can reinforce the conflicts that arose at the oral level, where an internalized conflict between dependency and self-soothing

becomes externalized and enacted within the social group (Guido et al., 2018). Genital Stage

Lastly, the genital stage manifests from puberty to death. The genital stage involves refining and developing strong sexual relationships with the self and others (Guido et al., 2018). It is learned that pleasure is not just about immediate sexual gratification, but also incorporates delaying gratification and building strong secure attachments. If individuals have successfully progressed through the psychosexual stages of development, then it is suggested the individual is well balanced and in a sense self-actualized.

Successful progress through each psychosexual stage suggested the individual was secure enough to overcome the conflicts at each stage, and thus avoided fixations (Kıvrak, 2018). There are infantile parts of the psyche that still live on within the adult that can be seen as dissolute chasers of immediate gratification (Kıvrak, 2018). For instance, individuals struggling with BN are burdened by intense cravings for large amounts of food in a small period of time, and find it extremely difficult to delay the intensity of such a craving. According to Freud, the overindulgence in food may be an unconscious representation of the mother’s overfeeding behaviour when the individual was a baby. Food may have been used to sooth a fussy baby. Successful progression through the psychosexual stages involves a balancing act between the animalistic pleasures demanding immediate gratification, and exhibiting patience by delaying gratification. It can be argued that BN patients struggle with an oral fixation, which suggests that they require immediate oral gratification, by way of: talking, eating, nail biting, and/or piercings. Fixations are developed when an individual was unsuccessful in mediating the conflicts at the oral, anal, phallic, latent, and/or genital stages of development. As an example, mothers who were unable to sooth their infant when needed, and/or unable to allow the infant to self-sooth,

arguably contributed to the increased risk of developing a fixation. This can unfortunately result in the infant becoming overstimulated and unable to determine how to soothe the self outside of eating. The more in which the anxious mother fed her child out of fear, the more in which the child internalized this fear and used the breast or bottle to sooth away the distress. Ultimately, the child learned that any form of distress – emotional, psychological, situational and/or biological – could be repressed by using food to mask the pain and enhance pleasure.

Defence Mechanisms

When psychoanalysts refer to the patient’s “personality structure” they are not only looking at the individual’s internalized world, but also the defence mechanisms that maintain the individual’s psychological, emotional, and relational distress. Defence mechanisms are used to protect the conscious mind from some overwhelming trauma. Freud argued that hysterical individuals attempted to treat their trauma by trying to avoid reexperiencing the traumatic event, and by extension evade intolerable pain (Wolf, Gerlach & Merkle, 2018). The process of defending one’s trauma through the use of defence mechanisms came at a great cost to the individual’s overall sense of functioning (Wolf, Gerlach & Merkle, 2018). Freud theorized that it would be beneficial for individuals to stop circumventing their trauma, and reexperience the pain in their mind so they can process the trauma and liberate their psyche (Wolf, Gerlach & Merkle, 2018). Individuals who are using these defence mechanisms are unconsciously driven to manage or avoid some threatening feeling centering on “anxiety” in the form of shame and/or grief (Wolf, Gerlach & Merkle, 2018), as well as the safeguarding of one’s self-esteem (McWilliams, 2011). Ego psychology would suggest that individuals unconsciously use defence mechanisms in order to defend against a form of anxiety. For instance, the onset of AN is suggested to occur in situations of high distress, including but not limited to: leaving for college,

moving out of the family home, and/or a family disturbance (Friederich et al., 2019). Object relations psychoanalysts will predominately focus on attachment. Defence mechanism are unconscious fabrications in response to the individual’s inability to process feelings, thoughts, and experiences associated with separation, abandonment, and/or death (McWilliams, 2011; Monajem, Monirpour & Mirzahosseini, 2018). Individuals who struggle with AN find it difficult to emotionally connect to others, whether this is due to issues surrounding trust, fear of rejection, and/or abandonment (Lingiardi & McWilliams, 2017). Those diagnosed with BN typically overindulge sexually, whereas they are binging on sexual gratification and often unconsciously associate a physical connection with a deep emotional connection (Lingiardi & McWilliams, 2017). Lastly, self psychologists argued that defence mechanisms were established to maintain an optimistic, robust, and a cherished sense of self (McWilliams, 2011). AN and BN individuals may view themselves as “too much” for people or “not enough,” which then is defended in the mind but acted out by way of restricting or compensatory behaviours.

Structural Model

Ego psychologists fundamentally focus on the structural intricacies of the psyche. Freud’s concepts of the “id”, “ego”, and “superego”, otherwise knowns as, “it”, “me”, and “above me”, predominantly focused on the possibility of breaching the conscious mind by way of wishes, dreams, fears, and fantasies (McWilliams, 2011). The id was a word used to highlight the animalistic part of the psyche, which housed a person’s drives, impulses, fantasies, wishes, and uncertainties. More specifically, the id is selfish, acts based on the pleasure principal, and is unable to delay gratification (Wooldridge, 2017b). Information derived from the id cannot be accessed by the conscious mind, the id is completely unconscious to the individual (Rennison, 2015). McWilliams (2004) argued that even though the id is entirely unconscious to the

individual, the existence of the id can be deduced from symbolic associations, including: dreams, intrusive thoughts, affect, and maladaptive behaviour (Rennison, 2015). The BN individual behaves from the id part of the psyche when impulsively binging on comfort food, satisfying some unconscious unfulfilled desire that is then replaced by food. The AN individual denies their primitive instincts, whereas the desire and necessity to seek nourishment to survive is masochistically denied.

Freud argued the ego began to emerge around the ages of 3 to 6, during the Oedipal/Electra stage, as a means to regulate the drives of the id in the “real” world (McWilliams, 2011). The ego functions upon the reality principle, which is grounded in logical reasoning and reality driven thought processes (Rennison, 2015). The ego can weigh the pros and cons before acting in a particular way, rather than impulsively acting in the moment. The ego can exhibit patience and withstand delayed gratification, where the desires of the id can be satisfied only given certain parameters (Rennison, 2015). For instance, AN and BN individuals may be aware of their intrusive thoughts and maladaptive behaviours yet are unconsciously compelled to act out their trauma through restricting, binging, and/or purging. This phenomenon is associated with a defence regarded as splitting, where the psyche is split between one part that observes one’s behaviour, thoughts, and feelings – otherwise known as the observing ego (Rennison, 2015) - while another part completely denies the reality of the situation (McWilliams, 2011). The role of the ego involves adapting to life’s chaos, what dialectical behavioural therapist refer to as “radical acceptance” (Görg et al., 2017). Essentially, the ego learns to adapt to situations in which the ego can act in accordance with the id. Having that said, the ego is able to reside within both the conscious and unconscious realms of the psyche (McWilliams, 2011). The ego is argued to proceed through the absurdity that is life, ready and able to accept both positive and negative

circumstances. The ego also can release tension - which was generated by unmet impulses from the id - by using higher order reasoning from the ego side of the psyche (Rennison, 2015). It is theorized the ego attempts to find certain objects within daily living that parallel the animalistic impulses created by the id in order to effectively process and manage id drives (Rennison, 2015). Seems as though the ego does not shy away from limitations or confrontation rather seeks to solve a problem directly. In some cases, such as situations of trauma, the ego may attempt to avoid the issue entirely using various defence mechanisms.

Freudian psychoanalysts stipulated that the superego began to surface around the age of five. The superego can move into the conscious and unconscious mind, building upon the moral dimensions of one’s personality acquired by society, culture, and one’s parental upbringing (McWilliams, 2011). One part of the superego is the “conscience” that is made up of the fearful consequences for “bad” behaviour, feelings associated with guilt and shame, as well as remorse (Rennison, 2015). An second part of the superego is the “ego ideal”, which are internalized standards or regulations for appropriate behaviour - which can either be real or perceived – that are constructed by society, school, work, and culture (Rennison, 2015). As an example, if majority of people associate beauty with thinness, and thinness with a high level of intrinsic value, then it is logical to deduce that those who do not fit the standard of “thin” are rendered insignificant. Impressionable individuals may internalize and associate that thinness is equivalent to having a sense of value and acceptance by others. Those who desperately want to avoid rejection, abandonment, and loneliness will work very hard to be accepted, and perceived as valuable. Thus, AN and BN individuals seem to go through great lengths to feel accepted by others, where they are literally dying to fit in.

Object Relations

Object relations psychoanalysts, such as Klein and Bion, outlined that object relations profoundly focused on the internalized love objects of the child, how the child experienced these objects, and how this emotionally impacted the individual (McWilliams, 2011; Ogden, 2018). More specifically, it was theorized that object relations involved a kind of psychological synthesis with another mind, and when this happens the mind of the self and the other become difficult to differentiate (Ogden, 2018). For instance, an AN individual may recall growing up with a mother who was cold, emotionally removed, and distant. The representation of “coldness” and emotional neglect from mom can become internalized, and unconsciously enacted through the behaviour of neglecting one’s necessities such as food. The AN individual may not be aware that their behaviour is directly associated with acting out the neglect experienced by mom. Until the individual can consciously contain the notion that their behaviour is an unhealthy way for them to act out their trauma brought on by these internalized objects, they are doomed to repeat such self-damaging behaviours.

Self Psychology

There were many “melancholic” patients who described their predisposition as purposeless, empty, and unable to decipher who they are. Most psychoanalysts viewed these melancholic patients as untreatable. However, Heinz Kohut (2018) conceptualized a new self psychology theory that seemed to parallel a kind of humanistic, existential approach, which incorporated the use of empathy to try and understand the patient’s relationship with the self and the world. It appears this study is in line with Kohut’s concept of self psychology, insofar as the exploration of symptoms, the mind and body, defence mechanisms, psychological structures, internalized objects, and the analysis of the existential self, combined can elicit an enriched and effective treatment modality for complex cases.

Contemporary Relational Movement

Modern psychoanalysts have begun to challenge the concept of a static and definite personality structure. Rather, it is believed that the “personality” is made up of many different “self-states” that manifest at various times and circumstances (McWilliams, 2011). Relational psychoanalysts are more interested in the therapeutic process, similar to the aim of this study. Not only are the self-states of AN and BN patients explored and discussed, the psychoanalyst’s self-states also play a significant role in the treatment process. This is the essential aim of the study is to explore this dynamic between the patient and psychoanalyst, from the perspective of the psychoanalyst.

Lacanian Psychoanalysis

Jaques Lacan was a French psychoanalyst who favoured the traditional workings of Freud. Lacan’s theoretical and practical approach to treatment was quite complex and will be generalized in this brief section. Fundamentally, Lacan wanted to bridge the gap between psychoanalysis and social theory, allowing one to essentially understand the self through the other by way of language (Hook, 2017). AN and BN patients have difficulty articulating themselves, especially in the presence of others, and thus desperately need to restrict, and/or binge and purge in order to satisfy their unspoken desires or needs (Busiol, 2021; Hook, 2017). Acting out is temporarily satisfying for the AN and BN patient, however there is no progress unless the AN and BN patient can articulate the psychic trauma(s) that are repressed in their mind (Hook, 2017).

Review of Research Literature

Comprehending psychoanalysis and what it means to provide psychoanalytic psychotherapy to AN and BN patients can be quite complex. Due to the heavy theoretical

component, it is understandable that educational institutions, such as the TPS&I, offer training programs that last from one to five years. Conceptualizing AN and BN cases, prior to exploring the dimensions of the psychoanalyst’s mind, seems beneficial as a means to obtain an understanding of the factors that can influence the onset of AN and BN. As previously outlined, there are many analytical theories, including relational and Lacanian psychoanalysis, that attempt to explain the human mind and behaviour. Nevertheless, it is also important to take note of the factors that can influence the onset of AN and BN. Therapeutic modalities, such as CBT, can aid in uncovering conscious intrusive thoughts. However, there are certain limitations to CBT as a treatment for AN and BN. Therefore, psychoanalytic psychotherapy aids in filling in the gaps left by CBT treatment, which includes observing the AN and BN’s unconscious mind.

CBT and Psychoanalysis

CBT therapists operate from the notion that individuals struggling with AN and BN are plagued by maladaptive thoughts about food and their body, which then induces a behavioural response such as restricting, binging, and purging (Agras, 2019). CBT therapists typically treat using a short-term model, which is highly structured, standardized, and centers on specific topics and exercises (Agras, 2019). The idealistic notion pertaining to CBT treatment suggests that individuals, whether struggling with depression and/or ED, can exhibit long-lasting change in six to twelve sessions (Agras, 2019). For example, a couple sessions may focus on perfectionism, other sessions may center on intense mood changes, and the final sessions might focus on self- esteem and interpersonal relationships. CBT may be helpful for those who are struggling with mild to moderate depressive and/or anxious symptoms. However, AN and BN are more complex mental illnesses that require a more specialized and long-term treatment approach.

Topics including perfectionism, intense mood changes, self-esteem, and interpersonal 31

relationships can take years to unpack. Like CBT, in a general sense, psychoanalysis focuses on the conscious and unconscious factors that impact one’s behaviour (Safran & Hunter, 2020). In other words, psychoanalysts observe and analyze what the AN and BN patient is articulating in session. However, the psychoanalyst is also listening to what the unconscious mind is saying, which can surface by way of images, dreams, as well as analyzing the words the patient uses (Safran & Hunter, 2020). Psychoanalytic psychotherapy provides AN and BN patients with a deeper understanding of their mind, uncovering painful associations, and processing the trauma in order to regain functionality (Safran & Hunter, 2020). Psychoanalytic psychotherapy is founded on the school of thought psychoanalysis, which includes several insightful theories. Previous sections outlined the significant theories affiliated with psychoanalysis, which focused on the collective theme of digging deeper past the patient’s symptoms to uncover the psychic trauma the symptom is attempting to cover up. The psychoanalyst will work with the AN and BN patient to uncover the unconscious associations and factors that contribute to the patient’s maladaptive behaviours. The factors that influence the onset of AN and BN are outlined in more detail below.

Psychoanalytic Diagnosis

There are some notable similarities and differences among AN and BN individuals with regards to their specific personality traits, affective states, cognitive states, physical states, and relationship dynamics. Research suggests that with regards to personality traits AN and BN individuals differ immensely. AN individuals are said to be more obsessive-compulsive and narcissistic (Lingiardi & McWilliams, 2017). Not only do AN patients restrict their food intake, but their self-induced deprivation is also then projected onto their inability to experience something new including relationships and opportunities (Lingiardi & McWilliams, 2017). The

analytical perspective outlines the onset of AN is more likely to occur during a time of development and drastic change, such as moving away to attend college or a sudden death in the family (Lingiardi & McWilliams, 2017). In this case, perhaps the individual’s superego is in hyperdrive, attempting to live up to the expectations of their loved ones and/or society. The pressure of transitioning into an adult can be traumatic in and of itself. Thus, individuals may rebel against their own development and regress back to a childlike state.

The BN individual, in opposition, is said to be more emotionally dysregulated and experience an emotional hunger, which is misunderstood by the conscious mind as a food craving (Lingiardi & McWilliams, 2017). The BN individual has also reported a sense of disgust towards the self, a self-loathing, and bottled-up rage (Lingiardi & McWilliams, 2017). Both the inability to articulate and regulate one’s emotions, while simultaneously experiencing an intense emotional craving, can elicit a severe attack on the self. The attempt to consciously fulfill an unconscious need is expressed in the form of binging and purging, which is defended against the individual’s raw emotions.

Aside from the uniqueness found in the AN and BN’s personality traits, symptoms, trauma and psychic trauma, the AN and BN’s affect, cognitive and somatic states, as well as relationship dynamic are found to be similar.

Adolescent

In this section AN and BN is explored from the psychoanalytic perspective, incorporating both the AN and BN adolescent as well as the AN and BN adult personality structure. Beginning with the adolescent, individuals experience an array of hormonal, physical, emotional, and psychological changes. During puberty both males and females may experiment with maladaptive eating patterns - including but not limited to binging, restricting, avoiding certain

foods, nibbling, craving, and hiding food - which is symbolically associated with individuation and the establishment of power (Lingiardi & McWilliams, 2017). Even though many adolescents may succumb to such problematic eating patterns at some point during their development, a small number of individuals develop a moderate to severe ED. Lingiardi and McWilliams (2017) highlighted, for females, atypical eating behaviours that occur around the premenarchal point in development may be a response to menstruation, and the anxiety that may surface associated with sexuality. More specifically, restrictive behaviours may be an unconscious attempt to stop one’s sexual maturation, which is observed in severe AN cases where the female’s body no longer menstruates otherwise known as amenorrhea (Lingiardi & McWilliams, 2017). The distorted perceptions of the AN psyche are projected onto the notion of sexuality and pregnancy, as if a distended abdominal during pregnancy is associated with obesophobia and thus must be eliminated. The AN and BN adolescent exhibits a wide range of psychic traumas that can influence their affective states, cognitive states, physical states, and relationship dynamics.

The affective structure of the AN and BN personality type suggest individuals have tremendous difficultly in identifying and expressing emotions. Lingiardi and McWilliams (2017) relay AN and BN individuals are exceedingly alexithymic, where they tend to experience more rapidly change and highly intense emotions that are difficult to regulate. Simultaneously, AN and BN individuals are preoccupied with the judgments of others, and are overly sensitive to the emotional responses of others (Lingiardi & McWilliams, 2017). In other words, AN and BN individuals do not consciously have the capacity to identify and elaborate on their affective state in detail. Thus, in a sense, AN and BN patients are regressing back to the nonverbal infancy stage. The AN and BN’s inability to articulate their emotions leaves them at risk for unconsciously acting out their emotions, such as the masochistic behaviour of restricting food

and/or violently inducing vomiting.

Cognitive patterns also exhibit a strong influence on the psyche, which then could

exacerbate maladaptive behaviours. Psychoanalytic research indicates that one contributing factor involves the notion of control, whereas AN and BN individuals experience a loss of control in their development from adolescent to adult (Lingiardi & McWilliams, 2017). Having that said, the AN and BN individual will unconsciously attempt to control their development so they can remain a child. For example, unconsciously using weight loss to remain small like a child, as well as inhibit the endocrine system preventing females from developing secondary sex characteristics (Lingiardi & McWilliams, 2017). Another significant aspect of the AN and BN personality type involves the explicit denial of one’s essential needs, a phenomenon that goes against one’s basic survival instinct.

The psychic and somatic confusion between the mind and body pose a significant threat resulting in the manifestation of an alexithymic response to eating (Burch, 1973). When AN and BN individuals find themselves in a stressful situation - rather than having the ability to articulate and process their distress - their emotions become internalized, and they begin to act out repetitive behaviours associated with restricting and/or engage in the binging and purging cycle to regain a sense of control (Burch, 1973; Lingiardi & McWilliams, 2017).

Lastly, AN and BN display similar traits regarding the discomfort they feel in social situations. Lingiardi and McWilliams (2017) argue the social discomfort may be an unconscious association with the overattachment to mom, and the anxiety experienced when the mother and child bond is severed. In other words, the AN and BN individual may unconsciously experience an arrest in their development as an attempt to maintain a childlike state, which in their mind is linked to a basic need of being cared for by a loving and nurturing mother. This wish may or may

not be associated with the traumatic exposure to a very cold, inattentive, and distant mother during childhood. Therefore, AN and BN patients crave the warm, nurturing, and loving mother. Rather than behaving in a warm, nurturing, and loving manner towards the self, the AN and BN individual overidentifies with the cold and inattentive mother. Thus, the pattern of neglect continues in the form of masochistic behaviours. Whereas the infantile need for a mother’s love and attention is represented by the food, which is either restricted and/or binged upon and then purged. It is also important to note that the attack on the self could also be projected onto others, creating a conflicting situation between those closest to the AN and BN patient.

Adult

Like the AN and BN adolescent, the AN and BN adult may experience feelings associated with anxiety, depression, alexithymia, guilt and shame, as well as impulsivity and risky behaviour (Lingiardi & McWilliams, 2017). However, when it comes to sexual impulses the AN individual tends to restrict or eliminate potential sexual interest, whereas the BN individual may experience an intense sexual craving and thus may display promiscuous behaviour. Finally, in both AN and BN individuals there seems to be unconscious rage affiliated with some psychic trauma from childhood, which is then projected within various social dynamics (Lingiardi & McWilliams, 2017). It is not uncommon for the AN or BN individual to vent or lash out at their psychoanalyst. Venting can be a necessary part of the treatment whereas the patient can learn to put words to their emotions, thoughts, and experiences. However, the AN and BN individual may then feel guilty or shameful for their aggression, and thus begin the attack on the self. Seems as though many AN and BN individuals can consciously access emotions such as despair and worry but have difficulty giving themselves the right to their anger. As if their anger is so dangerous it can destroy them and their relationships, so they don’t touch

it. Rather, they store it in the unconscious. The AN and BN individual’s rage does not stay hidden for long and thus can surface like a raging storm. It is important to help AN and BN individuals to allow themselves to put words to their anger, rather than aggressively acting out their rage. This is a big part of the treatment because guilt and shame can restrict the AN and BN individual from fully expressing themselves.

The AN and BN adult struggles with severe intrusive thoughts surrounding their body image, which includes negative self-talk and distorted perceptions about their body. According to Lingiardi and McWilliams (2017) AN individuals are perfectionistic, narcissistic, and self- critical, which is associated with specific defence mechanisms including omnipotence and idealization. Omnipotent control is associated with a kind of egocentrism whereas the individual believes they can influence their surrounding (McWilliams, 2011). Idealization involves an individual’s ability to assign a high level of power and importance onto those who one is emotionally dependent upon (McWilliams, 2011). Omnipotent control and idealization allow for the AN individual to continue restricting relationships with others and the self, ensuring that the cognitive states of the AN patient remain hidden from the conscious mind. BN patients experience more intrusive thoughts in association with their emotional dysregulation and experience an identity erosion (Lingiardi & McWilliams, 2017). Common defences exhibited within the BN personality structure, include but are not limited to splitting, “acting out” one’s internalized world, projective identification, as well as idealization and devaluation (Lingiardi & McWilliams, 2017). Splitting of the ego, also known as splitting, was briefly discussed Chapter 1. Splitting involves a divide within the psyche, where one part of the mind essentially thinks and acts one way, while another part of the mind thinks and acts in another way. The threat in this instance involves the BN individual’s inability to bridge the gap between the two sides of their

psyche. For instance, they are unaware that their binging and purging behaviour is an unconscious way to act out the intense emotions, thoughts and experiences buried within the unconscious. This example also incorporates the concept of acting out, where the BN individual is yet to obtain the insight necessary to bridge the gap between the dimensions of their psyche, thus are behaviourally driven to act out their psychic trauma (McWilliams, 2011). Klein and Bion outline the complex intricacies associated with the defence mechanism known as projective identification, which is said to be associated with the infant’s experience of a cold and distant mother resulting in a kind of infantile depression (Wollheim, 1960). Having that said, McWilliams (2011) argued that projective identification involves a deep attachment to loved ones insofar as to internalize their representations as a source for one’s identity. If the relationship with this idealized individual is severed, through separation or rejection, then the individual will feel a sense of diminishment due to the loss (Lingiardi & McWilliams, 2017). Rather than coming to terms and processing the loss and what has occurred within the relational situation, everything becomes internalized, and the BN individual then attacks the self as if the loss is entirely their fault.

The somatic states of the AN and BN adult can differ. AN individuals often disclose issues centering on abdominal and hunger pains, which may be an analytic representation of their emotional emptiness, the unmet desire of an emotional bond, or the unconscious desire for sex and/or procreation (Lingiardi & McWilliams, 2017). The BN individual can experience discomfort in the mouth and throat, which can analytically suggest they are putting some unmet need, unidentified emotion, and/or desire in their mouth and in the toilet (Lingiardi & McWilliams, 2017). What is most significant for both the AN and BN adult involves actively avoiding the sensation of feeling “full”, which is done by way of restricting food and/or purging.

Such somatic states in both AN and BN individuals elicit specific affective and cognitive states that either maintain or exacerbate ED symptoms.

Intimate relationships with AN and BN adults can be challenging. AN and BN individuals hide their thoughts, feelings and traumas from their own mind, which suggests the likelihood of them disclosing their struggles to others is low. Even though AN and BN individuals may want to establish meaningful romantic and platonic relationships, concurrently they are also fearful of rejection and abandonment (Lingiardi & McWilliams, 2017). Here is another example of splitting where one part of the psyche may want a romantic relationship and a family, yet another part of the psyche wants to stay away from people. This push and pull dynamic with romantic, platonic, and family relationships make it extremely difficult to maintain a close and personal relationship with the AN and BN adult.

Biological Implications

There seems to be a genetic influence that has contributed to the onset and maintenance of AN and BN. The hypothalamus plays a significant role in the regulation of eating behaviours. When the lateral hypothalamus is stimulated this elicits an eating behaviour in both humans and animals (Cassidy et al., 2019). When the ventromedial hypothalamus is stimulated, otherwise known as the feeding center, then eating behaviour stops (Cassidy et al., 2019). When both parts of the hypothalamus work in conjunction then individuals are able to maintain a healthy weight, because they are able to identify when they are hungry, able to eat until satisfied, and then stop. Research dictates that decreasing levels of epinephrine in the ventromedial hypothalamus is highly correlated with anorexic behaviours (Cassidy et al., 2019). A study conducted using rats found when epinephrine levels would decrease rats would then develop an increase in activity, a decrease in the rate of eating behaviours, and at times would compensate with overeating

(Cassidy et al., 2019). More specifically, it has been found that if serotonin is released within the lateral hypothalamus or ventromedial hypothalamus restricting eating behaviour surfaced. In opposition, if serotonin levels are significantly reduced then binging behaviours surface (Cassidy et al., 2019). This is one significant reason why psychotropic medications are commonly used to treat AN and BN symptoms, such as selective serotonin reuptake inhibitors (SSRIs).

Literature outlined the important role of the endocrine system showcasing that hormones, including orexin A and orexin B, are directly linked with eating behaviours in rats (Lebedev et al., 2020). When rats were injected with both orexin A and orexin B the rats began to eat almost ten times more (Lebedev et al., 2020). However, it is ambiguous whether decreased levels of orexin A and/or orexin B would contribute to restrictive eating behaviours. Berner et al. (2019) emphasized that the endocrine system was responsible for the way in which individuals regulate their sugar intake, which can directly impact hormones like ghrelin and leptin. Ghrelin is identified as the “appetite-increaser”, a hormone responsible for sending hunger signals to the brain (Berner et al., 2019). Individuals who are deemed obese are observed to exhibit lower levels of ghrelin, whereas AN patients struggle with an increased level of ghrelin (Berner et al., 2019). Leptin, on the other hand, is referred to as the “appetite-suppressing” hormone, which signals to the brain to stop eating (Berner et al., 2019). For instance, if BN individuals continually binge on junk food, then their sugar levels will continue to spike, which can elicit the body to store the sugar as fat rather expel the food as energy. The continual introduction of sugar in the body can hinder the effectiveness of the ghrelin and leptin hormonal processes, confusing the brain and body of its hunger and full cues (Berner et al., 2019).

Psychological Implications

There are many psychological factors that must be considered when discussing the onset 40

and/or maintenance of AN and BN. Obesophobia, as discussed previously, is characterized by the devastating and paralyzing fear of “becoming obese”. There are a number of different factors that are correlated with the manifestation of obesophobia, including but not limited to perfectionism and excessive worry (Robertson, 2003; Tokumitsu et al., 2016). Perfectionism involves the attempt to achieve an unattainable task in so far as to live up to some societal, cultural and/or parental expectation. The desperate need to be “perfect” plays a large role for the AN and BN patient, especially AN patients. For instance, AN patients can experience a heightened sense of worry with regards to social dynamics, such as worrying about the ways in which they may or may not fit in. In order to avoid rejection AN patients are desperate to ensure they live up to the social protocols of the group. This can include succumbing to maladaptive and/or risky behaviours in order to satisfy the real and perceived expectations of the group. Desperate to avoid rejection, the AN patient may become incapacitated and unable to voice their needs within the group, making it challenging to formulate secure attachments. The increased fear of rejection, which could be associated with a history of abandonment, then becomes affiliated with the need to fit in. In other words, one’s body image and the way in which they are perceived by others becomes the focal point of what is considered valuable, and is thus used as a criterion for acceptance into the group. A fear of rejection becomes misrepresented in the psyche as a fear of becoming obese, whereas weight gain can be unconsciously associated with the increased risk of rejection. AN individuals may hold the delusion that increased weight gain is associated with the decrease in intrinsic value, and individuals with less value are at an increased risk of rejection.

Food addiction is another factor that can contribute to disordered eating. With the use of the Yale Food Addiction Scale (YFAS) Meule et al. (2014) found that majority of BN individuals

are categorized as “food addicted”, in the same capacity as obese and binge eating disorder (BED) individuals. Addiction treatment fundamentally centers on substance dependency as the primary issue. For BN patients food addiction is not the primary concern. Thus, treatment for BN should incorporate the exploration of what the food covers up. As stipulated previously, BN patients do not have the capacity to articulate their pain and anguish, rather they plug their mouth with food as an attempt to cover up their pain. Covering up one’s emotions, thoughts and/or experiences using food may be sufficient in the short-term, however guilt and shame then surface. The BN individual must again defecate or vomit their thoughts, feelings, and experiences into the toilet, and flush away what they cannot say.

Social Implications

Research had previously stipulated that AN and BN diagnoses are predominantly present in young, white, financially well-off females. Mulders-Jones et al. (2017) found that AN and BN were found among individuals of different income levels, educational levels, indigenous status, as well as employment status. Results of the study also unveiled socioeconomic indicators and ED associations, whereas: working full-time was associated with an increased risk in binging and purging, unemployment was linked to binge eating behaviour, over engagement with household chores was associated with the internalized evaluation regarding one’s weight or body shape, and lastly those with a trade or certification qualification exhibited increased risk associated with restricting and/or yo-yo dieting (Mulders-Jones et al, 2017). AN and BN symptoms were also found among indigenous individuals, both males and females, disclosing a history of purging and excessive exercising (Mulders-Jones et al, 2017). Even though past research has stipulated a specific demographic and socioeconomic profile of AN and BN individuals, current research has revealed there are many more people from various cultural and socioeconomic groups who also

struggle with AN and BN.

Family dynamics can also play a significant role in the onset and/or maintenance of AN and BN. Enmeshed families pose a psychological threat insofar as to stunt the AN and BN individual’s ability to establish their own identity, develop self-soothing capabilities, as well as learn how to regulate their emotional response. For instance, families with the best intentions might unintentionally attempt to solve their loved one’s problems and/or strongly encourage their family member to live up to some idealistic expectation. Even good intentions can have sour ramifications. Studies have shown that over-involved families, as well as enmeshed families, create a dynamic where the AN and BN patient experiences a sense of powerlessness (Cerniglia et al., 2017). Alongside the AN and BN individual’s limited emotional capacity, blurred boundaries make it near impossible for family members to establish a healthy and secure family structure. Thus, the developmental progression of a well-adjusted individual can become obscured. As an example, parents of teenagers may have strict rules regarding socializing and curfew. Boundaries may not be blurred, however due to the parents’ heightened levels of worry they become over-involved in their teenager’s life. Some teens, certainly not all, exhibit a kind of emotional and/or psychological suffocation under such strict parental rulings, and therefore push back as an attempt to establish control, independence, and dominance (Cerniglia et al., 2017). Such deviant behaviour may include sneaking out of the house late at night and lying about one’s whereabouts. Other teens may not be able to push the parental boundaries in the same manner, and thus take it upon themselves to control what they eat, don’t eat, and what they put in the toilet. Overprotective, and perfectionistic parents can also have a negative impact on a developing mind (Cerniglia et al., 2017). In other words, the notion of value and success becomes externalized. Where AN symptoms and BN compensatory behaviours are viewed as a

way to try and establish, or re-establish, a sense of control by restricting, binging, vomiting and/or defecating. Unfortunately, as research dictates, for the struggling AN and BN patient their attempt at regaining control through weight loss is futile.

Trauma

The exposure to trauma can also have devastating effects on an individual. Not every person who is exposed to a traumatic event develops an ED. However, there is research to suggest a correlation between posttraumatic stress disorder (PTSD) and ED. According to the DSM-5, a diagnosis of PTSD cannot be stipulated without criterion A, which outlines that a traumatic event includes the exposure to the threat of bodily harm, or the witnessing or experience of sexual violence (American Psychiatric Association, 2013). Brewerton (2007) recognized several different types of traumas that were associated with AN and BN, including but not limited to childhood sexual abuse and interpersonal trauma (Mitchel et al., 2012). Based on Brewerton’s (2007) findings it is important to take note that individuals who struggle with PTSD are at higher risk for developing an ED. However, understanding the association between PTSD and ED, as well as comprehending the development of this multilayered ailment is still uncertain. Research suggests that a traumatic event causes a significant disruption in the autonomic nervous system (ANS), where the sympathetic nervous system is constantly activating the fight or flight mode (Milosevic, 2015). From an evolutionary perspective, the sympathetic nervous system was used as a built-in alarm for humans to avoid dangerous situations (Milosevic, 2015). The body releases chemicals, such as adrenaline, to fuel the body to fight or run away from the dangerous situation. Once the individual is away from the danger the parasympathetic nervous system becomes activated to relax the body (Milosevic, 2015). Individuals who struggle with PTSD experience the activation of the sympathetic nervous system

during typical day-to-day excursions. It becomes difficult for the individual to calm the body down, and thus the parasympathetic system becomes inhibited. The disruption of the ANS is correlated with one’s inability to regulate their emotions, and as can begin to use food and/or psychoactive substances to cover up their intense emotions (Milosevic, 2015). For instance, victims of sexual abuse may attempt to restrict their food intake to distract the mind from the negative intrusive thoughts, as well as try to reduce their attractiveness because in their mind this will decrease the risk of revictimization (Sack et al. 2010; Yehuda 2001). Brewerton (2007) stipulated that BN rates where exponentially higher in those with a history of rape and a diagnosis of PTSD, compared to those who have a history of rape without a diagnosis of PTSD, and those without a history of rape. The results of Brewerton’s research suggest there is a correlation between PTSD and ED. However, the details of the onset and maintenance of these complex ailments is still perplexing.

In addition to the exposure of a traumatic event it is also significant to highlight the influence of a psychic trauma on an individual. As addressed in Chapter 1, psychoanalysts describe a psychic trauma as a psychologically damaging experience that yields an emotional disruption, mental disorder, or a long-lasting negative impact pertaining to the way in which one internalizes their self-concept (McWilliams, 2011). For instance, the impact of a cold, emotionally neglectful, and emotionally abusive mother growing up can contribute to the adult child’s fractured internalized psyche. For instance, the child may grow up to become a very insecure adult, engaging in harsh self-criticism, and break their back to try and achieve perfection. The mother’s disposition, and the interaction between the mother and child may not look like a traumatic event as defined by the DSM-5. However, research has found that similar interpersonal dynamics, especially between a mother and child, have been associated with

teenage and adult ED symptoms (Lingiardi & McWilliams, 2017). From a psychoanalytic standpoint, even though the AN and BN individual may have established their independence and separated from the mother, the AN and BN individual continues to internalize the cold mother. The internalized cold and neglectful mother hinders the psyche and bombards the mind with negative thoughts. Even though the AN and BN adult may function relatively well, such as in their studies or at work, they become oblivious to their achievements as if they are insufficient in some capacity. This internalized failing or lacking can then be illogically associated with one’s body image as a misrepresentation of their self-worth. Therefore, traumatic events and psychic traumas can both leave a devastating mark on the individual’s psyche.

Parenting Style

Outlined in the Drive Theory section of this paper, parenting styles can have a drastic impact on the child’s development, especially the development pertaining to their personality structure. As an example, a strict parenting style might contribute to the child’s development related to a more anal-retentive personality structure Guido et al., 2018). There are four different types of parenting styles: authoritarian, authoritative, permissive, and uninvolved. An authoritarian parenting style is characterized by a strict adherence to the household rules, without any exception (Johnson, 2018). The authoritarian parent does not allow for the child to explore, make a mistake, or solve their own problems. Often the authoritarian parent is the one controlling the dynamic of the situation, giving very little freedom to the child. The authoritative parent aims to establish a positive and warm environment, articulating the reasons in which rules are established, and having a conversation with the child to help them understand why the rules are in place (Johnson, 2018). Authoritative parents typically use discipline techniques that help the child learn from their mistakes and understand there are consequences for “bad” behaviour.

The permissive parenting style involves adopting a carefree attitude, overly forgiving, setting flimsy boundaries that are rarely enforced, and adopt a friend-child relationship rather than establish a parent-child dynamic (Johnson, 2018). Unfortunately, children of permissive parents are more likely to become adults who typically push boundaries, exhibit a sense of entitlement, and have difficulties combating egocentrism (Brisman, 2017). Lastly, the uninvolved parenting style can be understood in reference to the movie Matilda. Matilda was a young girl who was very bright and filled with potential, however her parents did not foster her gifts nor paid very much attention to her at all. The child in this dynamic essentially raises their self, most likely growing up with an internalized sense of abandonment (Lingiardi & McWilliams, 2017). All four parenting styles contribute to the development of the child’s psyche, what is deemed acceptable behaviour, as well as how they view and interact with themselves and others in the world.

“Finish what is on your plate” is a common phrase used to represent a household rule that food should not be wasted. The authoritarian parent, forcing their child to finish what is on their plate, seems to be an unintentional way to disrupt the healthy regulation of one’s endocrine system. The image here is that there is too much on the plate and the child cannot ingest anymore food. Analytically, it seems as though the child is experiencing too much parent, the over- involved parent, and is trying to rid the self from the overbearing parent represented by the food. The continued dynamic could result in an adult unconsciously internalizing the overbearing parent. Without conscious recognition of the psychic trauma the individual is driven to act out the theme of “too much”, possibly in the form of binge eating, promiscuous sex, and/or impulsive activities (Lingiardi & McWilliams, 2017). With the authoritative parent the child is more likely to feel comfortable in articulating their needs, such as feeling full, which would be

received with warmth and empathy. In this situation empathy, education, and parenting rules play a significant role in parenting young children, allowing them to learn and grow. Treatment Recommendations

Many different healthcare professionals will recommend various treatment approaches depending on their diagnostic assessment of the AN and BN patient. Physicians and psychiatrists may recommend medications such as antidepressants. In the section Biological Implications, research by Cassidy et al (2019) discussed the ramifications of increased and decreased serotonin levels in the lateral hypothalamus and ventromedial hypothalamus, suggesting that SSRIs are a beneficial way to help regulate the electro-chemical responses in the brain. In other words, by regulating the chemical imbalance within the brain the hypothalamus can function efficiently, thus minimizing or eliminating restricting, binging, and purging behaviours. Other medications, such as antianxiety or antipsychotic medication may also be prescribed depending on the patient’s disposition. It is not uncommon for an AN and BN patient to possess a prescription for their ED symptoms, as well as depression and anxiety symptoms (Bello & Yeomans, 2018; Marvanova & Gramith, 2018). Even though there is research to suggest the benefits of psychotropic medication there are many AN and BN individuals who refuse medication. There are many reasons in which AN and BN individuals may refuse medication, including but not limited to: moderate to mild side effects from the medication, it can take months even years to find an appropriate regimen, as well as the increased fear of gaining weight by ingesting the medication (Bello & Yeomans, 2018; Marvanova & Gramith, 2018). Unfortunately, for individuals whose ED is active will most likely attempt to maintain their misguided goal to lose weight, and thus refuse or lie about taking their medications as prescribed.

Psychotherapeutic treatment is another viable option. Psychotropic medications are 48

biological interventions used to reduce or eliminate the patient’s symptoms. Psychotherapy works in a similar fashion using psychological approaches to focus specifically on the patient’s cognitive faculties, interpersonal relationships, the patient’s relationship with the self, and/or exploration of the unconscious mind. Krass et al. (2018) addressed that the most common evidence-based psychotherapeutic model that is widely used, and accepted by most insurance companies, is CBT. CBT as well as interpersonal psychotherapy (IP) have been shown to help improve BN symptoms (Krass et al., 2018). Studies also suggest that family-based interventions are proven to be most effective for BN youths (Krass et al., 2018). Family therapy, specific to AN, includes a highly structured assessment and treatment approach for both the patient and their family members (Simic et al., 2021). Even though there is research to suggest the effectiveness of CBT, IP, and family therapy, there are also significant limitations. One major limitation involves the duration of treatment. For instance, insurance companies may dictate a fixed number of therapeutic sessions, and once those sessions are completed the patient is either forced to pay out of pocket or decide to terminate treatment. Most insurance companies value a structure and short-term treatment model, which may be useful for some patients. However, due to the complex nature of the AN and BN diagnostic structure short-term therapy is not an appropriate treatment methodology.

Psychoanalysis is a long-term treatment modality that allows the AN and BN individual to explore their mind, including but not limited to: their positive and negative associations, discussing their internalized objects such as growing up with their parents and siblings, any trauma and/or psychic trauma, dreams, as well as how they feel. Based on certain psychoanalytic theories, the psychoanalyst will adopt a practical approach based on their favoured psychoanalytical orientation. For instance, a Lacanian psychoanalyst will focus primarily on the

AN and BN individual’s use of language, and how the patient is articulating their subjective mental structure (Moncayo, 2018). Object relations psychoanalysts will fundamentally focus on the interpersonal relationships with others, and the ways in which these relationships are represented in the AN and BN individual’s mind (Mintchev, 2018). One, seemingly universal analytical technique, involves the use of free association. Free association allows the AN and BN individual to speak their mind, whether their thoughts seem significant or trivial, they essentially have come to session to interact freely with their mind (McWilliams, 2011). Projectives, such as an inkblot test, may also be used as an assessment tool to decipher what the AN and BN individual may be projecting, and allow them to elaborate on their narrative (McWilliams, 2011). The reason in which psychoanalysis is long-term, and why research has deemed this approach effective, is because it takes time to break down the barriers of the mind in order to process the repressed trauma (Hamburger, 2020). Psychoanalysis is not for everyone. Not everyone is interested in long-term therapy, and not everyone is interested in facing the trauma within their psyche. Therefore, it is the job of a competent healthcare provider to complete a thorough assessment and construct the most effective treatment plan for the specific individual.

Nutrition counselling, offered typically by a dietitian, involves educating AN and BN individuals about nutrition, information about their metabolism and how the body functions, as well as construct a personalized meal plan (Hay, 2020). Additionally, dieticians can determine the level of treatment needed for the AN and BN individual, such as the need for inpatient versus outpatient treatment (Hay, 2020). Dieticians may have some training in counselling, but mainly provide treatment in the form of nutrition and monitoring the AN and BN individual’s body mass index (BMI). Without proper psychotherapeutic treatment and/or medication the treatment plan provided by a dietician can, for the AN and BN individual, pose to be a restricting approach that

might trigger unconscious traumatic associations (Heruc et al., 2020). In other words, an interdisciplinary treatment team, including a psychiatrist, clinical psychologist and/or psychotherapist, as well as a dietician can logically yield significant results in decreasing AN and BN symptoms (Heruc et al., 2020; McMaster et al., 2021). Ideally, the treatment team can work together to help support the AN and BN individual by addressing the biological, psychological, and social influences connected to the ED. Unfortunately, not all individuals are able to access these resources or can afford the intensive treatment approach.

As previously outlined, family therapy is a significant part of the overall treatment, especially for children and teens who struggle with AN and BN. If it is the case that intrapersonal and interpersonal relationships are a significant part of ED treatment, then it is essential to include family therapy as beneficial adjunct to treatment. Research by Russel et al. (1987) found that family therapy was more effective than individual treatment, where symptoms of AN was reduced more so in those who engaged in family therapy. Simic et al. (2021) also stipulated the power of family therapy for AN patients, where both individual and family therapy can help reduce AN symptoms. Comprehending the dimensions of one’s own mind and building secure relationships with loved ones through family therapy seems to diminish AN and BN symptoms (Simic et al., 2021). Due to the complex nature of AN and BN family therapy is typically regarded as a vital component within most inpatient programs.

Methodology Review

There is a significant amount of literature that focuses on the quantitative exploration of the effectiveness of various ED treatments. For instance, there are various experimental designs comparing one ED group that received medication and psychotherapy, another ED group that received psychotherapy, another ED group that received medication, and another ED group that

received no treatment. Results typically stipulated that ED patients who received both medication and psychotherapy reported less ED symptoms, compared to the other groups (Hilbert et al., 2019; Zhu et al., 2020). There is also a long list of studies that quantitatively compare different psychotherapeutic modalities. As an example, psychoanalysis and CBT were compared with regards to the effectiveness in reducing AN and BN symptoms. The results suggested that there was a slight increase in effectiveness with regards to the long-term psychoanalytic treatment of ED, compared to a more short-term CBT approach (Haverkampf, 2017). Research by Fonagy (2018) implies psychoanalysis is founded in evidence. Even though psychoanalysis as a staple evidence-based practice remains thin, there is a structure that is maintained throughout psychoanalytic treatment (McWilliams, 2004; Solms, 2018). For instance, it is important for the psychoanalyst to hold the frame, even in situations when patients try to resist or fight the frame (McWilliams, 2004). The frame incorporates a set of boundaries the psychoanalyst places upon the treatment, including but not limited: to date, time, location, fee, and any communication inside and outside sessions (Tylim & Harris, 2017). AN and BN patients are typically resistant towards treatment in many different ways, such as being late to session or refusing to pay for session, in which case the resistance must be analyze within the transference (McWilliams, 2004; Wooldridge, 2017a; Wooldridge, 2017b ). There is a structure and certain capability the psychoanalyst possesses in order to get at the AN and BN patient’s core fantasies (Wooldridge, 2017b).

A meta-analysis that centered on classical Freudian psychoanalysis determined there was empirical evidence to suggest clinical change in patients with complex mental illness (Paris, 2017). Even though there is a wide range of quantitative research concerning ED treatment, there really is limited information concerning what ED treatment fundamentally entails. Quantitative

research predominately focuses on elements of causation, as well as explore effectiveness of treatment. Quantitative methodologies provide a more general perspective of AN and BN presentation and treatment process, but do not provide a detailed description of what these influential factors entail or explore the dynamics of treatment. Therefore, an in-depth exploration of the treatment process is justified, and is accomplished by the use of a qualitative approach.

Synthesis of the Research Findings

The literature was found using a variety of resources including the Capella Library, and PEP Web. Aside from the literature review, data was also collected from participant interviews, which will be addressed in more detail in Chapter 3. There was a significant amount of research regarding AN and BN symptoms and treatment. However, as stipulated, there was less research pertaining to the treatment of AN and BN using psychoanalysis, and there was even less information concerning diverse populations. It is clear that AN and BN are complex ailments that encumber the individual and their loved ones (Wooldbridge, 2017b). It appears the complexity of AN and BN does not only include symptomology, but also one’s ability to formulate attachments with the self and others (Lingiardi & McWilliams, 2017). Individuals struggling with AN and BN experience a wide range of issues, including but not limited to problematic eating, interpersonal and intrapersonal struggles, risky and impulsive behaviour, subject to magical thinking, an inability to identify and regulate one’s emotions, exhibit suicidal ideation, display resistance, as well as fall victim to the cycle of relapse (American Psychiatric Association, 2013; Lingiardi & McWilliams, 2017). Healthcare providers argue what treatment approach would be most beneficial for AN and BN patients. Medical providers, such as psychiatrists, treat using a biological approach in the form of psychotropic medication. Clinical providers treat using psychotherapy, such as CBT or psychoanalysis. Dieticians treat by way of

educating the AN and BN patient about nutrition, as well as help develop their social-self by way of fostering healthy attachments with the self and others (McMaster et al., 2021). These various providers work from their own theoretical framework to conceptualize and treat the patient’s AN and BN ailments.

Critique of the Previous Research Critique of the Literature Review

To understand the complex dimensions of AN and BN one must first identify the dynamic factors that contribute to the onset and maintenance of both disorders. The comprehensive exploration of the multilevel AN and BN facets, such as various biopsychosocial components and manifestation of symptoms, involve a meticulous search for sound research. Qualitative validity is used to assess the literature to ensure the information explored about AN and BN is credible, reliable, dependable, transferable, and confirmable (Schmidt, 2017). In the advancement of psychological research, it is imperative to utilize credible sources. Analyzing the credibility of the literature involves a scrupulous process of authenticating the credentials of the authors, understanding and evaluating what was discussed in the study or book, and ensure that the information provided is up to date and relevant (Schmidt, 2017). The literature review in this chapter was founded on the use of peer review articles, as well as books written by reputable authors. The information was presented in such a way as to outline the various theories within the school of psychoanalysis, address the associating factors that contribute to the onset and/or maintenance of AN and BN, evaluate and critic the literature, as well as highlight the limitations and the need for future studies.

Reliability is another important dimension when trying to decipher between sound research, compared to other inaccurate and outdated sources. It is important to use reliable

databases when searching for credible sources. Reliable databases included the use of Pep Web, which encompassed specific information about psychoanalysis offered by the TPS&I. The Capella Library is another excellent database used to acquire peer reviewed articles.

Summary

This chapter began with a brief description of the prevalent psychoanalytic theories: drive theory, defence mechanism, Freud’s structural model, object relations, the contemporary relational movement, as well as a brief introduction to Lacanian psychoanalysis. Review of the Literature dove more into the components of AN and BN, including: the psychoanalytic perspective of AN and BN, the biopsychosocial components that correlate with AN and BN symptoms and behaviours, history of trauma, parenting styles, treatment recommendations, and lastly a methodology review. The following section focused on a synthesis of the findings, which outlined the purpose of the research. The final section of this chapter, Critique of Previous Research, presented an evaluative structure pertaining to the trustworthiness of the literature review.

CHAPTER 3. METHODOLOGY

The expectation for Chapter 3 involved outlining nine key factors, which included: the purpose of the study, research question, research design, target population and sample, procedures, instruments, present the interview questions, address data collection and analysis, ethical considerations, as well as qualitative accuracy. Some of the information addressed in Chapter 3 was briefly outlined in Chapter 1, including the purpose of the study. The general aim in this chapter is to outline in detail the steps taken to complete the study.

Purpose of the Study

The purpose of the study aimed to investigate the psychoanalyst’s treatment perspective, as well as explore the relationship between the psychoanalyst and AN and BN patient. With regards to the psychoanalytic relationship, the emphasis is placed on the resistance, pertaining to the AN and BN personality structure, and how the psychoanalyst and patient attempt to build a healthy relationship that allows for the understanding, breakthrough, and processing of those resistances as a means to get to the psychic trauma (Lingiardi & McWilliams, 2017). For instance, the psychoanalyst attempts to build a relationship with the AN and BN patient who has difficulty trusting the psychoanalyst. The AN and BN patient cannot take in, or accept, the psychoanalyst as a helper. Rather, the AN and BN patient projects their unconscious associations surrounding mistrust onto the psychoanalyst in order to unconsciously self-sabotage the relationship (Lingiardi & McWilliams, 2017). In other words, AN and BN patients can begin to unconsciously, and without agency, act out their trauma and relive their anguish. Thus, the AN and BN patient’s inability to build trust with the psychoanalyst makes it tremendously difficult for the patient to have insight into their own psyche. How can the psychoanalyst and the AN and

BN patient build trust and establish a psychoanalytic relationship when there are layers of resistances? How does the psychoanalytic relationship foster the treatment process, and help breakdown the resistances?

The purpose of the study was to explore the psychoanalyst’s treatment perspective and experience working with patients diagnosed with AN and/or BN. The research specifically involved comprehending AN and BN psychoanalytic treatment to explore what occurs within the transference and countertransference, examine the details of the AN and BN personality structure, as well as discuss the dynamics pertaining to the psychoanalytic relationship. This was done by interviewing seven participants who confirmed they have used psychoanalysis to treat AN and/or BN patients.

In addition to exploring the phenomenon of AN and BN psychoanalytic treatment, this study is also intended to aid in spreading awareness within the field of psychology and the mental health community. It would be favourable if awareness pertaining to the enriched psychoanalytic approach to ED treatment would surface as an invaluable treatment within the scientific community.

Research Question

Conceptualizing AN and BN dynamically yields vital and detailed information about the AN and BN personality structure and symptoms, compared to other therapeutic interventions. It was fascinating to uncover what happened to a psychoanalyst when they treated AN and BN patients. In particular, what would manifest during the transference and countertransference? How does the psychoanalyst manage the AN and BN patient’s aggression and other resistances? What is involved in establishing a psychoanalytic relationship? The research question for this

study is, how would the psychoanalyst describe their experience providing psychoanalytic treatment to AN and BN patients?

Research Design

For this study a qualitative design was most appropriate since the aim was to explore the experience of the psychoanalyst, and to identify and understand what occurs within the transference and countertransference. This is done as an attempt to comprehend the complexities of psychotherapeutic treatment with AN and BN individuals. A qualitative approach allowed for the direct communication with different psychoanalysts to explore their perspective in treating AN and BN individuals, identify elements of the psychotherapeutic relationship, as well as investigate the dimensions of the ED treatment session. Data obtained from the interviews provided enhanced information about the experience of the psychoanalysts, which then elicited: information about the treatment process itself, the problems observed with regards to attachment, as well as explore the internalized self-concept. During the interview process the psychoanalyst’s self-concept was explored by diving into their psyche and speaking about their attachments, defence mechanisms, and/or enactments within session.

The interviews were conducted via telephone, and were audio recorded as a means to transcribe the discourse. Participants that volunteered to be interviewed had training in psychoanalysis and have worked with AN and/or BN patients. There were seven participants who volunteered to be interviewed, and they had a choice to be interviewed via telephone or video. The interview itself consisted of seven standardized questions and culminated in a 20 to 30 minute interview. The information provided by participants was considered valid, since there was no way to verify their personal and professional anecdotal experiences. The psychoanalytic education and credentials of each participant was verified using the licensing board directory, as

well as the psychoanalytic society directory.

Target Population

Population

The procedures relevant to this study did not include the recruitment of vulnerable participants, such as those diagnosed with AN and/or BN. Rather, the study population included the recruitment of nonvulnerable participants, such as clinical psychologists and psychotherapists who have treated AN and/or BN patients using psychoanalytic psychotherapy. The research pertained to the exploration of the psychoanalyst’s perspective, experience, and relationship treating AN and BN patients.

Sample

A sample size of 10 to 12 participants is typically deemed a sufficient size to reach data saturation within qualitative research (Boddy, 2016). The original aim of this study was to recruit ten participants however it was found that not many psychoanalysts treat AN or BN patients. Having said that, recruitment was expanded to a larger population in order to identify seven participants, at which point the data reached saturation and data collection was discontinued.

The recruitment process involved sending out emails to members, affiliates, and guests of the TPS&I and TICP. Individuals who responded to the invitation to participate were screened for eligibility. Participants eligible for the study were licensed clinical psychologists or psychotherapists who had training in psychoanalysis, and have treated AN and BN patients using psychoanalytic psychotherapy. There were over 20 people who were interested in participating but ineligible to contribute since they did not work with the AN or BN population. The seven individuals who were eligible completed a 20 to 30 minute interview addressing their experience and relationship with their AN and BN patients, diagnostic perspective of the AN and BN

patient, how they measured progress, as well as reflect upon what manifested within their countertransference during the treatment. All seven interviews took place via telephone, and were audio recorded to transcribe the correspondence.

The IRB granted approval for this study as a minimal risk study. Participants had the right to withdraw at any time during the interview process. It was also made clear to participants - within the consent form and during the interview process - that they could choose to have their interview revoked from the data analysis if they felt it necessary.

Procedures

Participant Selection

Psychoanalysts were invited to participant in a 20 to 30 minute interview, discussing their experience treating AN and BN patients. Participants were found using the TPS&I and TICP directories and were sent email invites. Many participants responded to the invite, however not many met the criteria for the study. Inclusive criteria for the study involved: (a) mandatory training in psychoanalysis or psychodynamic psychotherapy, (b) hold a supervised or autonomous license as a clinical psychologist or psychotherapist, and (c) have treated AN and/or BN patients using psychoanalytic psychotherapy. Psychoanalysts who presented with an active eating disorder were excluded from the study. As long as participants met the eligibility criteria and did not exhibit an active ED - which was discussed during the pre-screening and again during the interview- then those psychoanalysts could partake in the study.

The interview was completed via telephone and was audio recorded to transcribe the conversation as a means to complete a thematic analysis. Participants were informed – via email, informed consent, and at the beginning of the interview – the information obtained during the interview will be kept confidential as per the CPO and IRB guidelines. Individuals were

provided with the informed consent and told they could reach out at any point if they had questions about the study, and/or how their personal information was managed. By signing the consent form, and completing the interview, participants agreed to the policies and procedures outlined for the study. Participants were also made aware that they could terminate the interview at any point and/or revoke access to their private information. Psychoanalysts who qualified for the study were scheduled for an interview. The following steps were taken to comply with the IRB recruitment process:

1. Recruitment strategy and materials were approved by the IRB.

2. Templated recruitment email, which was approved by the IRB, outlined a summary of the

study, inclusion criteria, and important contact information.

3. Potential participants responded to those emails and were screened for eligibility. If the

participant was not eligible for the study, then an interview was not scheduled.

4. If the participant was deemed eligible then they were provided with the informed consent,

and an interview was scheduled.

5. Participants were provided with a signed copy of the consent form prior to the interview.

There were two participants who experienced technical issues, and thus provided verbal

consent during the interview and written consent following the interview.

6. During the beginning of the interview the participant’s willingness to partake in the study

was confirmed.

7. Before, during, and after the interview participants had the opportunity to ask questions

and voice any concerns.

8. A telephone interview was conducted and audio recorded.

Protection of Participants

Participants were protected in many ways throughout the recruitment and interview process. Participants were protected by way of:

1. Participants were provided with clear and detailed information about the study. Including but not limited to the nature of the study, the potential risks involved, as well as how one’s private information was managed.

2. Ensure participants understood the parameters of the study, what was asked of them, awareness of any potential risks, as well as comprehend how their private information was managed.

3. Consent was provided in written and verbal form as a means to verify the participant’s willingness to partake in the study.

4. Interviews were scheduled according to the participant’s schedule.

5. Informed participants when the recording began and stopped.

6. The audio recording obtained following the interview, and transcribed conversation were

both stored on an encrypted USB drive.

7. The encrypted USB drive will be destroyed in ten years following the last interview.

After the interview all data obtained was stored on a secured USB drive as to comply with

CPO and IRB regulations. The data will remain on the encrypted USB for ten years, as per CPO guidelines (College of Psychologists of Ontario, 2021). Once a decade has past, since the last interview, at that point the USB drive will be destroyed in order to protect the privacy of participants.

Role of the Researcher

Instruments

The role of the research can depend on many different factors, including the design of the study and the research question. For this study what was important were the researcher’s credentials, active listening as a means to comprehend the psychoanalyst’s perspective and experience, as well as collaborative thinking. Exploring the role of the researcher in these parameters helped to highlight the detailed methodological process that will allow for future researchers to replicate.

Credentials

Competency is one of the codes of conduct outlined by the CPO, as well as other governing licensing boards. Competency involves working within one’ own scope of practice, and not subjecting vulnerable people to any form of harm (College of Psychologists of Ontario, 2021). In other words, it would be considered unethical to embark on a clinical research study without understanding the parameters and delicate dynamics of the psychological phenomena being studied, as well as the factors that could significantly impact the study and/or participants. Clinical and academic incompetency within a psychological research study could lead to extensive harm, whether intentional or not, to patients and participants. For example, a patient may be triggered in session - or a participant could be triggered during the interview – in which case it is up to the clinician or researcher to reduce the level of harm and keep the patient or participant safe. This was one reason the exclusionary criteria for this study included psychoanalysts with an active eating disorder, as to ensure the safety of participants during the interview. Additionally, participants were able to debrief following the interview - which was not audio recorded as a means to protect the participants’ privacy - as well as provide any follow up

correspondence as needed.

Theoretical and practical experience in qualitative research was limited, so competency

was established through academic resources and research supervisor consultation. Gaining the knowledge and skills required to conduct a thematic analysis involved comprehending a standardized way of collecting and analyzing data. Additionally, experience in writing a qualitative research paper was also limited. In order to obtain the knowledge and skill needed to write a research paper Capella resources were used to aid the learning curve.

Listening

The interview process was conducted in a similar way as one would approach a psychoanalytic therapy session. Psychoanalysts like Bion stipulated, that a psychoanalytic therapy session should be approached with no intent and no desire, simply allow the session to flow as it naturally would (Bléandonu, 2020). The role of the researcher in this case involved sitting with the participant in the moment to try and comprehend their subjective experience.

Theodor Reik theorized that the psyche had the ability to decrypt the deep unconscious thoughts and feelings of another, as that person was attempting to articulate the workings of their conscious mind (Sutanto, 2021). To put it in another way, the psychoanalyst can decipher the abstract content and imagery the patient provides the psychoanalyst, this is done as the patient is freely speaking about whatever surfaces in their mind (Sutanto, 2021). The significant component here for the psychoanalyst is to work towards obtaining the ability to listen with a third ear, and help the patient identify their psychic traumas and ultimately uncover the inner workings of their mind.

It was mandatory that this study followed the approved research proposal as per IRB stipulations. Therefore, the interview questions were semi-structured to establish an empirical

framework; there is more to be said about the interview questions in the Guiding Interview Questions section. The frame for the interview provided a way for participants to stay on topic about the significant dynamics pertaining to AN and BN treatment, including: exploring the psychoanalyst’s overall experience working with AN and BN patients, comparing a DSM-5 diagnosis of AN and BN to a psychoanalytic diagnosis, analyze the psychoanalytic relationship with their AN and BN patients, investigate what occurs within the transference and countertransference, determine if there are any enactments that manifested, and find out how the psychoanalyst measures progress. The frame allowed for participants to stay on track, whereas the general and open-ended questions aided participants to freely associate concerning their thoughts, feelings, behaviours, and experiences.

Collaborative Thinking

Most therapeutic techniques, including CBT and person-centered therapy, involve the use of collaborative thinking. For the psychoanalyst, it is their duty to sit with the patient wherever they go on their thinking path (McWilliams, 2004). Mutually exclusive from desire and control, the psychoanalyst explores with the patient their current mental state, allowing for the patient to make sense of their own mind (McWilliams, 2004). This technique was applied to the interview process, where the role of the researcher involved following the participant through their explanations, associations, elaborations, fantasies, countertransference, insights, knowledge, skill, and resistances. The methodological approach included both summarizing and asking probing questions to foster the participant’s thinking process. Silence was also used as a technique, such as a brief pause, as an additional way to spark the participant’s unconscious thoughts and feelings. These basic, but effective, therapeutic techniques gave way to the participants describing their experience in more detail.

Guiding Interview Questions

As stipulated previously, the interview questions were semi-structured focusing on the psychoanalytic relationship between the ED patient and psychoanalyst, AN and BN diagnostic structures, transference and countertransference, as well as progress. The questions were open- ended and general insofar as to spark a conversation, or an unconscious association pertaining to the participant’s experience treating AN and BN patients. Participants were not provided with the interview questions in advance, as to ensure the participant’s genuine and unfiltered response. The following questions were asked:

1. In your experience what was it like treating AN and/or BN patients using psychoanalysis?

2. In your opinion what is the difference between a DSM-5 diagnosis of AN and/or BN, compared to a psychoanalytic diagnosis?

3. Can you explain the relationship dynamic between you and your AN and/or BN patient?

4. Can you describe what manifests within your countertransference during session?

5. What, if any, are some of your defence mechanisms that have surfaced in a

session?

6. What if, any, enactments have manifested during session?

7. How do you measure progress, or change, dynamically with AN and/or BN

patients?

These interview questions were constructed by the researcher based on a moderate to

strong understanding of psychoanalytic theory and practice, as well as a professional 66

understanding pertaining to the complexities of AN and BN.

Data Analysis

Data Collection

Data for the study was obtained primarily through interviews, asking important questions, and striking insightful conversations about AN and BN psychoanalytic treatment. Interviews were scheduled at a convenient time for participants and conducted via telephone using a login- protected iPhone. Another login-protected iPhone was used to audio record the interviews. The interviews were saved on a Macbook Air computer, and then immediately transferred and saved on an encrypted USB. To ensure confidentiality, and abide by CPO and IRB regulations, there was no identifiable information on any of the audio recordings.

The essence of the interview questions was derived from the psychoanalytic literature, as well as general information associated with the case conceptualization of AN and BN. Semi- structured interview questions focused on the psychoanalytic relationship between the patient and psychoanalyst, AN and BN diagnostic structures, transference and countertransference, as well as progress in treatment. The idea was to follow the general treatment process, which included diagnosing, treating, and measuring progress (Clarkson & Pokorny, 2013; McWilliams, 2004). This was included within the study frame where the interview questions were open-ended to permit participants to freely associate. However, the questions were also constructed in a semi-structured fashion, which gave way to the researcher partially guiding the interview as a means to stay on track discussing AN and BN psychoanalytic treatment. Within the study frame participants were free to discuss whatever came to mind. Participants were told the interview would take about 20 to 30 minutes, but there was no time constraint thus participants could talk as much or as little as they wanted. Following the interview participants had an opportunity to

debrief, ask questions, and voice their feedback.

Data Analysis

The audio recordings collected following participant interviews reveal no identifiable information, and were coded to ensure further security. Numeric codes were used in order for the researcher to categorize and organize the data prior to completing the thematic analysis (e.g., 001 and 002). Audio recordings of each interview was transcribed, and each transcribed interview was then stored on the same encrypted USB that stored the initial audio recording. Following each interview, the researcher transcribed the interview using Microsoft Word. Interviews were transcribed following each interview in order for the researcher to become familiar with the data, which aided in the smooth completion of a thematic analysis. Following the thematic analysis, the data that was obtained for this study remained on an encrypted USB drive which was stored in a locked cabinet in a home office. The data obtain for this study will be saved for ten years, and then physically destroyed in order to maintain confidentiality, as well as the integrity of the study.

A thematic analysis was used in order to analyze and interpret the data. A thematic analysis is defined as a specialized method for analyzing qualitative data by organizing the raw data in such a way as to unveil significant trends or themes (Clarke & Braun, 2014; Maguire & Delahunt, 2017). The data was analyzed and interpreted using a six-step approach, which helped to ensure the data was empirically analyzed using a standardization process. Clarke and Braun (2014) constructed a six-step approach to analyze the data using a thematic analysis, which included: familiarization, coding, generating initial themes, reviewing the themes, labelling and defining the themes, and writing the report.

Step 1: Familiarization of the Data Collected

Familiarization of the data requires the researcher to listen, read, think, and/or reflect upon the data (Clarke & Braun, 2014; Maguire & Delahunt, 2017). Increasing familiarity with the data helped the researcher to be in a better position to successfully progress through the remaining five steps. (Clarke & Braun, 2014; Maguire & Delahunt, 2017). The methodological process of familiarization in this study involved listening to the audio recordings multiple times prior to transcribing, completing the transcription process thoroughly and with care, as well as reflect upon each of the seven interviews.

Step 2: Coding the Data

Following the transcription process the data was explored and coded. Coding involves identifying the general features of the raw data (Clarke & Braun, 2014; Maguire & Delahunt, 2017). This was done by highlighting certain parts of the transcribed text, such as relevant words and phrases, as well as any other significant content. The coding phase involved identifying certain trends in the data as a means to begin organizing the data into manageable categories (Clarke & Braun, 2014; Maguire & Delahunt, 2017). The raw data was organized using the MAXQDA Analytics Pro program. The raw data, both the audio recordings and transcribed interviews, were uploaded to the software system. The analytics software program made the coding process very simple and straightforward. As outlined previously, no identifiable information was revealed on the audio recordings, or the transcribed interviews.

Step 3: Generating Initial Themes

Following the coding process there were many words, phrases, paragraphs, and other content that was highlighted. Different highlighters were used for different concepts and trends. At this point in the thematic analysis the codes need to be looked at more closely in order to identify initial themes (Clarke & Braun, 2014; Maguire & Delahunt, 2017). In this study the

MAXQDA Analytics Pro program helped to categorize the different colours of the text, allowing the researcher to view all the content that was highlighted with the press of a button. Since the software program exhibited numerous “friendly” features, it was easy to view the highlighted text via colour and begin to gather initial themes. In other words, the more generalized and unrelated data could be separated from the significant ideas or themes that required more refining.

Step 4: Reviewing Themes

Reviewing the themes required the researcher to ensure that the themes identified from the raw data are adequate and suitable for the study (Clarke & Braun, 2014; Maguire & Delahunt, 2017). With regards to this study, it was vital that the raw data collected aimed to answer the research question and open a dialogue about AN and BN psychoanalytic treatment. To sufficiently review the themes, the aim was to ensure that the initial themes that were generated were associated with the parameters of the research question, and were ultimately pertinent to the study. Information that was not associated with the research question, or relevant information about AN and BN psychoanalytic treatment was dismissed.

Step 5: Defining and Labelling the Themes

Defining and labelling the themes helped the researcher to set specific parameters and distinctions concerning the data (Clarke & Braun, 2014; Maguire & Delahunt, 2017). More specifically, this step permits the researcher to properly organize the data, as if the raw data is moving along a refining mill, granting the researcher effective organization of the refined raw data. The labelling process required the researcher to validate the data that was collected and refined, and then decide on whether the data is relevant to the study (Clarke & Braun, 2014; Maguire & Delahunt, 2017). This process was done carefully by reviewing the research question

and purpose of the study outlined in Chapter 1, reviewing the literature in Chapter 2, as well as reflect upon the essence of the study and determine if the themes identified helped to tell the AN and BN story from the psychoanalyst’s perspective.

Step 6: Writing the Report

The final step involved writing the report, which should be a formally written paper outlining a literature review, methodology, results, observations, as well as conclusion (Clarke & Braun, 2014; Maguire & Delahunt, 2017). For this study, this research paper would be considered the “formal report”, which has outlined all the significant parts of a qualitative dissertation. It is important to note, there were no outside sources used to conduct the study or write the report.

Ethical and Other Considerations

Ethical Compliance

It was vital for the researcher to ensure that the study, participant interviews, data collection, interpretations, and presentation of the data complied with the ethical guidelines outlined by the CPO and IRB. According to the CPO, conduct code 7.2 outlines that clinicians and researchers are required by law to provide informed consent (College of Psychologists of Ontario, 2021). For instance, it is important that participants are provided with a clear outline of what to expect from the study and interview process. Otherwise said, it is important for both patients and participants to clearly understand what they are engaging in, and what potential consequences there may be.

Secondly, it is important the researcher warrants that participant information, including but not limited to emails, signed consent, audio recordings, and documents are kept secure and confidential (College of Psychologists of Ontario, 2021). Data was protected using passcode

protected devices as well as an encrypted USB that was stored in a locked cabinet. Confidentiality was maintained insofar as not to allow third party access to the raw data, and certify no identifiable information was shared in this dissertation.

Lastly, it was the role of the researcher to confirm there was minimal risk to participants during the study (College of Psychologists of Ontario, 2021). The research proposal approved by the IRB outlined minimal risk to volunteers. To mediate risk, it was important to stipulate an exclusionary criterion where psychoanalysts who disclosed an active ED would not be eligible to participate in the study. In other words, it would be unethical to invite psychoanalysts with an active ED to partake in the interview. If, for instance, the psychoanalyst is triggered, and unable to contain what is manifesting within their psyche, the debriefing process following the interview would not be sufficient to reduce harm. Therefore, it was deemed ethically sound to exclude psychoanalysts who actively struggled with AN or BN.

Qualitative Accuracy

Qualitative credibility refers to the precision of the data as stipulated by the participant, as well as a thorough and comprehensive interpretation by the researcher (Belotto, 2018; Willig, 2017). Credibility also has to do with the process in which the study enhances the believability of the findings over time, and over various conditions (Belotto, 2018; Willig, 2017). Assessing credibility within qualitative research involves demonstrating one’s understanding of the research methodology, in addition to how well one can apply a standardized process concerning data collection and analysis (Belotto, 2018; Willig, 2017). With regards to the recruitment and interview process, participant credentials were verified using the TPS&I and TICP directories. Participant credentials pertaining to their license as a registered psychotherapist or clinical psychologist was also confirmed using the licensing board directories, the College of Registered

Psychotherapists of Ontario (CRPO) and CPO. It is important to note, it was difficult to verify the psychoanalyst’s anecdotal experience working with AN and BN patients, and what the particular analytical process looked like for each psychoanalyst. Therefore, it was deemed appropriate to accept what participants were saying as truth about their history treating AN and BN patients using psychoanalysis.

To achieve dependability within the research it was vital to outline the step-by step details of the study (Belotto, 2018). The reason it was so important to address, in detail, the step- by-step process was to ensure another researcher can replicate the study, including: the reason for the study, an exhaustive account of the recruitment process, a step-by-step framework of the screening and interview process, as well as a six-step outline of the thematic analysis that was conducted (Belotto, 2018; Willig, 2017).

Transferability can be understood in terms of generalizability (Maxwell, 2021). In other words, transferability is validated by indicating that the sample represents the target population. In this study it is difficult to determine whether the sample group fully represents the population. Having said that, generalizability is not the goal. This is one significant reason a nonprobability sampling methodology was used to aid in the recruitment process. The fundamental aim of the study was to shed light and comprehend the psychoanalyst’s experience, as well as gain an understanding of their perspective on what it means to treat AN and BN patients using psychoanalytic psychotherapy. Psychoanalysts within the population may have different experiences with different AN and BN patients, thus it would have been difficult to account for generalizability. Hence, it is the richness of the narrative addressing the complex dynamics between the patient and the psychoanalyst, which in and of itself is the essence of this study. To enhance transferability, it is the responsibility of the researcher to elaborate on the narrative and

assumptions that were the focus of the research (Belotto, 2018). This can be done by asking probing questions, and summarizing the participant’s statements.

Summary

Chapter 3 addressed the methodological approach to the study, as well as the step-by-step process concerning how the research was conducted. The drive that ignited this study involved outlining the serious gaps in research and practical application in treating AN and BN patients, and that a psychoanalytic approach needed to be explored. Investigating the psyche of the psychoanalyst was a way to explore the research question, how would the psychoanalyst describe their experience providing psychoanalytic treatment to AN and BN patients? To answer this question a generic qualitative design was constructed to examine the intricacies of the psychoanalyst’s mind regarding their history treating AN and BN patients. Participants were found using two reputable psychoanalytic directories. Credentials of the participants were verified. However, participant’s description of their experience could not be verified, and thus what participants disclosed about their experience was deemed “true”. The interview questions generally focused on the psychoanalyst’s experience treating AN and/or BN patients, AN and BN personality structures, psychoanalyst’s specific defence mechanisms and/or enactments, transference and countertransference, as well as progress. Data was collected using an audio recording device, and the interview was transcribed in order to complete a thematic analysis. Chapter 4 will go into detail about the thematic analysis, as well as present the themes that have surfaced.

CHAPTER 4. DATA COLLECTION AND ANALYSIS

This chapter addresses the study results and unveils the data collected from participants, results of the thematic data analysis, as well as the findings. The final puzzle pieces are starting to come together to formulate a picture, a picture of what it is like to treat AN and BN patients.

Introduction: The Study and the Researcher

The Study

The investigative drive that perpetuated this study involved comprehending the delicate relationship between the psychoanalyst and AN and BN patient. Psychoanalytic literature outlined the extent to which AN and BN patients struggle interpersonally and intrapersonally but neglected to describe what the struggle looked like. It was speculated that the AN and/or BN patient would act out their insecure attachments within session with the psychoanalyst, and that the treatment itself fundamentally involved establishing a secure psychoanalytic relationship. The significance of the psychoanalytic relationship as a fundamental component of the ED treatment surfaced during the interview process with all seven participants.

The literature review in Chapter 2 discussed the various psychoanalytic theories including: object relations, relational analysis, Freud’s structural model, as well as defence mechanisms. Chapter 2 also presented the psychoanalytic structure of the AN and BN patient, biopsychosocial components, history of trauma, parenting styles, treatment recommendation based on the literature, as well as evaluate the reliability and dependability of the literature.

Chapter 3 provided a detailed overview of the methodological approach of the study by way of providing a step-by-step account of the research process. A thematic analysis was the most appropriate analytical approach aiding in organizing and interpreting the data. Through the process of transcribing, coding, refining, and labeling allowed for significant themes to arise

Clarke & Braun, 2014; Maguire & Delahunt, 2017). While conducting the thematic analysis three pertinent themes surfaced – relationships, emotional distress, and treatment limitations – which will be discussed in more detail in the section Presentation of Data and Results of the Analysis.

The Researcher

Data collection was obtained by way of interviewing seven participants. It was the role of the researcher to comprehend the participant’s psychoanalytic perspective and experience working with AN and BN patients. Comprehension was gained by way of asking probing questions, clarifying questions, as well as summarizing what participants said to ensure accuracy of the information being provided. The interview questions were semi-structured and open- ended, which allowed for participants to freely associate based on the question provided. The interview questions centered on the psychoanalyst’s overall experience, DSM-5 diagnosis compared to a psychoanalytic diagnosis of AN and BN, transference and countertransference, presence of any enactments, as well as how the psychoanalyst measured progress. The role of the researcher also included audio recording the interviews using a password encrypted smart phone, as well as transcribe the interview as a means to conduct a thematic analysis.

Description of the Sample

There are many clinicians that have attempted to treat AN and BN patients using various psychotherapeutic approaches, including but not limited to CBT. For this study it was important to look outside the box and explore the dimensions of a psychoanalytic approach to AN and BN treatment since standardized psychotherapeutic interventions, such as CBT, fall short (Haverkampf, 2017; McWilliams, 2004). An analytical perspective allowed for a much richer examination of the AN and BN treatment process, what is means to suffer from AN and BN,

interpersonal and intrapersonal struggles, as well as what happens to the AN and BN patient from the perspective of the psychoanalyst.

There were seven participants who provided significant information pertaining to the multilayered relationships, the patient’s psychic trauma, emotional baggage, resistances, and the limitations to standardized treatment. Personal information including but not limited to age, race, culture, sexual orientation, and years practicing was not discussed. However, there were two participants who identified as retired, whereas the other five participants identified as actively practicing. Participants were found within the Greater Toronto Area in Ontario, Canada. Participants were recruited using the TPS&I and TICP directories, which included the contact information of the members, affiliates, and guests of both societies. TPS&I and TICP are both reputable organizations that focus on providing knowledge and training in psychoanalysis. Certification in psychoanalysis typically includes coursework, direct contact with patients, supervision, and the inclusion of one’s own psychoanalytic treatment (Toronto Institute for Contemporary Psychoanalysis, 2021; Toronto Psychoanalytic Society and Institute, 2021).

Recruitment involved sending out mass emails to psychoanalysts on the TPS&I and TICP directories. Eligibility for the study included licensed clinical psychologists or psychotherapists, who had training in psychoanalysis, and had treated AN and/or BN patients using psychoanalytic psychotherapy. Exclusionary criteria included psychoanalysts who are diagnosed with an ED and are actively struggling with ED symptoms. Participants were asked to complete a 20 to 30 minute telephonic interview focusing on their experience treating AN and/or BN patients. Interviews were audio recorded, and then transcribed to complete a thematic analysis.

Research Methodology Applied to the Data Analysis

A generic qualitative approach was used to analyze the in-depth interviews provided by 77

seven insightful participants. The interviews were semi-structured and open-ended to allow psychoanalysts to freely discuss whatever came to their mind. The researcher approached the interview with no agenda. The interviews were audio recorded, and then transcribed to complete a thematic analysis.

A software program, MAXQDA, was used as a means to organize the data obtain from the interviews. Interviews were first transcribed carefully using Microsoft Word. The transcribing process took on average two to six hours per interview, whereas interviews ranged from 20 to 40 minutes in duration. Audio recordings of the interviews were listened to very carefully and transcribed as accurately as possible. Following the transcribing process, audio recordings of the participant interviews were reviewed in correspondence with the written interview to ensure consistency, as well as familiarization. Familiarization is a part of the thematic analytical process, which involved getting to know the data insofar as to notice patterns and/or reoccurring themes (Clarke & Braun, 2014; Maguire & Delahunt, 2017). Prior to the identification of particular themes, the interviews were coded using MAXQDA. The coding process comprised of filing various segments of the interviews into different categories and subcategories to aid in the identification of significant patters and/or repetition of words and phrases (Clarke & Braun, 2014; Maguire & Delahunt, 2017). The final processes involved refining the patterns, words and phrases, and cluster the data in such a way as to unveil significant themes (Clarke & Braun, 2014; Maguire & Delahunt, 2017). Basically, the process involved an on ongoing filing system, refining the subcategories and any subcategories in those subcategories, to ultimately formulate refined categories or themes. The themes identified were then listed and prioritized to see which themes held more weight. The reference to “weight”, in context of data analysis, refers to the richness of a theme, and what the theme has to offer the study. The aim was to collect data from

participant interviews to analyze the data as a means to answer the research question. The themes identified are regarded as the conclusion and findings for this study. Lastly, it is important to note there were no problems to report during the data collection or analysis process.

Presentation of the Data and Results of the Analysis

Presentation and interpretation of the data will be addressed with reference to three pertinent themes: relationships, emotional distress, and treatment limitations. Using the software program MAXQDA information from the transcribed interviews was coded by highlighting the text and making notes. Clarke and Braun’s (2014) six-step thematic approach to analyzing the raw data was used, which included: familiarization, coding, generating initial themes, reviewing the themes, labelling and defining the themes, and writing the report. After the data was coded the first step of the refining process began, which included generating initial themes. Generating themes involved a process of clustering the highlighted data into categories, which was identified as the initial generated themes. Upon reviewing the initial themes another refining process took place in order ensure the information was adequately categized, labelled, and defined. All in all, the raw data was refined using Clarke and Braun’s six-step thematic analysis, which aided in unveiling three specific themes, along with other significant subthemes that support the primary theme.

Theme 1: Relationships

Relationship dynamics between the mother, father, the family unit, the self, as well as the relationship between the psychoanalyst and patient posed to be the most significant themes. Participants provided vital information about what the AN and/or BN patient experienced with regards to their intrapersonal and interpersonal relationships, as well as described what their relationship was like with their patients. An in-depth analysis of the seven interviews revealed

that a secure, open, and warm relationship fostered growth. Having said that, all seven participants stipulated, insecure attachments established by emotionally cold and/or distant parents have perpetuated the internalized attack on the self, which then exacerbates AN and BN symptoms.

Mother

The relationship between patients and their mother, according to participants, seemed to reveal some interesting information. I005 reported, “parents are extremely important”, I005 continued to say, “I never really felt engaged [with] the mother in understanding what had gone wrong in their [the patient and mother’s] relationship”. Here is an example of “not enough mother”. The mother, according to I005, was not involved with the patient because the mother viewed the patient as a “problem child”, and thus not involved in the patient’s treatment. It seemed as though, according to I005, the patient was acting out her restricting behaviour in such a way as to address her psychic trauma of not having enough mother. In other words, for this patient, not having a mother to provide unconditional love, warmth, kindness, patience, and understanding resulted in an unconscious attack on the self.

Power and control also seemed to play a role. I003 stated, “she’s [the patient’s mother] expecting her [the patient] to eat that’s why she’s not eating”. In this situation I003 explained that his patient was acting out against the mother’s control over the patient, and it gave the patient an unconscious sense of pleasure not to eat. As if it were a kind of attack on the mother, the overbearing mother. In this case there was “too much mother”. The relationship with the mother seemed to be important, according to all seven participants, suggesting AN and BN patients will remain stuck in their illness if they are unable to build healthy and secure attachments with their mother.

Father

One, out of seven participants, discussed a male patient diagnosed with AN who exhibited intense anger. I002 told a story about a male patient who became upset with her and vandalized her office. I002 stipulated, the following session the patient “came into [session] extremely sheepish and apologetic which would be the same type of dynamic that had been at play with his dad who is pretty aggressive with him”. Based on I002 her male patient was significantly impacted by his father’s aggression, so much so the patient would act it out in session. I002 expressed she did her best to try and create a safe space, psychoanalyze the patient’s trauma pertaining to his father’s aggression, as well as clearly address the seriousness of the patient’s aggressive behaviour.

Family Problems

The chaotic family dynamic can also have an impact on the AN and BN patient, with regards to the way they interact with family members as well as how they treat their self. I005 stated that the “negative relationship between a mother and a father ... was pretty destructive to this young person”. This general dynamic within the family has repeated in other interviews with participants as well. I003 and I004 discussed the significance of the mother and daughter relationship insofar as to contribute to the onset and/or maintenance of the ED. I002 spoke about the dynamic pertaining to aggression regarding the son and father relationship. Unfortunately, children may become innocent bystanders in the catastrophic war that is divorce. Parents arguing and neglecting their child’s needs can be detrimental. For I005’s 12-year-old patient, she felt as though she was not getting the attention she deserved from her parents. Therefore, the patient acted out the neglect on herself by refusing to eat. In this case, the instability within the family dynamic also seemed to be represented in the psyche of the patient.

Intrapersonal Relationship

Relationship with the self is tremendously important, which includes emotion identification, validation, and having a platform to feel heard. When individuals have a positive relationship with the self this suggests they are aware of their intrinsic value and will act in accordance with that value (McWilliams, 2004). Individuals who have a negative association with their self may unconsciously hinder or even attack the self, preventing the self from achieving self-actualization (McWilliams, 2004). Those who have a negative relationship with the self, and who are unable to voice their distress, continue to suffer in silence. I004 stipulated, “what can’t be represented the body will take up the organs will take up in a psychosomatic way”. In other words, what cannot be articulated will then be represented in the body by virtue of symptoms, including but not limited to restrictive or chaotic eating behaviours.

Psychoanalytic Relationship

The psychoanalytic relationship incorporates the dynamic between the patient and psychoanalyst, with respect to the strategic and systematic ways psychoanalysts treat patients. For instance, one participant played a very active role in the treatment of her ED patient who was malnourished and suicidal. I004 relayed, “I allow her [a] kind of access [that] I might not be as comfortable with other patients, in other words that she can text me or call me anytime except after a certain time of night”. This patient, according to I004, was on the brink of death and felt that a neutral psychoanalytic standpoint would elicit the message of a cold and useless mother. The notion of “withholding” in session can be represented by the patient as an unconscious projection of the mother and father’s emotional suppression and/or neglect, which was then recreated within the transference. I004 explained, “I felt extremely worried about her and concern about the rate of responsibility I had in forming a relationship with her and that all

would be directed within the relationship including her suicide attempts”. Taking on a very active role, allowing patients certain freedoms such as texting outside office hours can be taxing on the psychoanalyst. I002 expressed, “it’s very slow and painstaking work”, “it’s going to be a rough ride and you have to be able to roll up your sleeves and sort of get a little bit dirty”. Not only is it difficult work, but psychanalysts at time can get just as frustrated as patients. I003 expressed,

“So, my anger I wouldn’t take it as it is necessarily. I know though I think this is part of the process. So, if I feel something I may say okay is this mine or is this from the person, and I will try to ask questions about their experience. Not about mine. I will then take that as a prompt to interpret something in the other”.

Even though psychoanalysts experience this rough rollercoaster ride, when working with AN and BN patients, they still attempt to promote a warm and nurturing space. The safe space, along with patience, openness, and nurturing approach to treatment allows for the slow establishment of a secure attachment. The secure attachment within the psychoanalytic relationship is, according to participants, said to aid in the patient’s progress in treatment. I004’s approach involves making “their own internal space bearable to them, making them more comfortable in their own skin”. I002 helped patients feel “comfortable getting through the stage”, breaking through barriers, and building insight together.

When a secure attachment is formulated within a psychoanalytic treatment - the construction of the psychoanalytic relationship - progress can begin. In other words, AN and BN patients have difficulty establishing trust and thus building a healthy relationship with the self and the world. Once a psychoanalytic relationship is established, according to participants, the AN and BN patient can begin to find their own sense of worth, validation, and meaning in their

life. I005 mentioned that one patient progressed within treatment, so much so she was able to individuation by going to university. I005 relayed, “I can remember feeling very pleased that she was able to go away from her parents... And get to go to university and live her life”. I005 mentioned her 12-year-old patient who struggled with AN and select mutism was able to, “speak to me from her hospital room ... And she had her mother there and she had her father there and I’ve never seen her happier”. Feeling connected and able to express oneself seems to be a by- product of establishing a secure and healthy relationship.

Connect vs Disconnect

In situations where participants provided a very warm, patient, and welcoming demeaner can induce the feeling of comfort, and thus can enhance the patient’s trust and thinking process. Interviews with participants such as I003 discussing a Lacanian approach to treatment was very intriguing, as well as the playfulness of I004 using humour as part of the treatment and interview. With participants who were able to keep the interview light, welcoming, and warm, the dynamic within the interview was electric and the information was very detailed. It is argued that participants who were able to exude a warm demeaner during the interview also present in this manner during session with AN and BN patients.

There does seem to be a pattern, where positive interactions foster enriched conversations. Whereas negative, or complicated, interactions can impact one’s ability to focus, critically analyze their psyche, as well as find difficulty in coming face to face with one’s mind in a safe space.

Theme 2: Emotional Distress

All seven participants, in one way or another, painted the picture of what it looked like for the AN and BN patient to be weighed down by their psychic traumas. It was also interesting

to note that psychoanalysts also felt weighed down at times during the ED treatment. Part of the patient’s resistance to treatment – especially with regards to finding a way to exhibit vulnerability, trust, as well as build a psychoanalytic relationship – is defended by feelings associated with anger, abandonment, distrust, and chaos. In other words, the trauma(s) that are stuck in the mind wreak havoc on the patient’s internalized structure, and what is produced out of fear and/or self-preservation is a kind of emotionally dysregulated shield.

Anger

Anger seems to be an interesting emotion that is not always discussed in detail, but is actively or passively present, and can impact the dynamic between the self and others. I005 explained,

“The difficulty that the young person has relating to their parents in an emotionally meaningful way, a lot of anger directed at them and disappointment... Help them [the parents] understand that the children are really needing to have a connection with you, that they feel they need in order to go forward but that falls on deaf ears”.

As if the parents choose not to hear the child, the child may then begin to feel invisible. As a result, the child acts out their feeling by essentially becoming invisible through the avoidance or neglect of food. In other words, the patient begins to treat their food the way in which they feel they are being treated by others.

Participants also noted their frustrations within their own countertransference, aimed to contain what was theirs and what was their patient’s frustration, and then spoke about receiving supervision/consultation and/or their own personal psychoanalysis. I003 expressed that he would “contact my supervisor, one of two, I have to discuss cases... And it was to ensure I was positioning myself properly, but I talk about that in my own analysis”. It is not uncommon for

complex and/or negative emotions to surface in session. However, it is up to the psychoanalyst to contain what is occurring within their own countertransference, as well as help the AN and BN patient elaborate on their associations and interpretations.

Abandonment

Abandonment refers to being and/or feeling left alone, without a safety net, and without direction (Guex, 2018). According to participants, most if not all AN and BN patients felt a sense of abandonment from a parent. I003 articulated the projection of mom’s emotional neglect and/or distance “could be an expression of rejection, she’s projecting all the negative in mom”. In other words, AN and BN patients can unconsciously project the internalized abandoning mother, feeling neglected or rejected in session with the psychoanalyst. If this continues to be acted out in the transference without being adequately analyzed, then the AN and BN patient is doomed to continue unconsciously projecting the abandoning mother in all aspects of their life.

During the interview process participants indirectly expressed worry that their patient may abandon them. For the participant, this form of abandonment may be expressed through the AN and BN patient’s self-harming behaviours, suicidal intent, confrontation between the psychoanalyst and patient, and/or the patient’s fear of becoming vulnerable and building a relationship with the participant. I007 explained, “suicidal patients in the beginning when I began to treat patients, I found myself extremely afraid of how close to death they often were”. Even though participants can do everything they should do, according to the CPO code of ethics, sometimes it does not seem enough. Sometimes patients lash out - such as I002’s male AN patient who could not regulate his anger - as an unconscious way to abandon a relationship before it fully forms.

Distrust

It is not uncommon for AN and BN patients to distrust others, especially if they were conditioned as young children to rely only on themselves. Participants explained, when AN and BN patients grow up in an environment where mom is emotionally cold and neglectful, and dad is distant and unavailable, patients begin to learn they can only rely on themselves. This is a heartbreaking realization for the young child looking for love and attention from nurturing parents. I002 mentioned, “they [AN and BN patients] become highly suspicious and distrusting, and it’s hard to locate what exactly causes that. Whether they’re starting to feel very vulnerable, or something else”. Participant I002 reported that AN and BN patients have grown up believing they could not trust anyone, and if they trusted someone they would suffer the negative consequences. Psychoanalytic treatment allows for the slow and steady, yet “painstaking”, process of building trust in order to form a strong therapeutic foundation.

Chaos

The chaos that can arise, situationally and in the psyche, can cause great distress. Participants have expressed that a split can reside in the AN and BN patient’s psyche, which can be associated with the battle between wanting to stay a child and seek out an idealized nurturing parent, and the need to individuate and become an adult that nurtures the self. Participant I004 stipulated, “purging is ridding herself while she wants to stay a child and wants the parental involvement of a parent, she also wants to rid herself of the toxic aspects of the parents”. Participant I003 adds, “in bulimia I find it slightly different in terms of these aspect of the binging or purging that leads to a factor of chaos, it’s in a way more disorganized”. In other words, the BN patient may feel as though their life is chaotic, they have many responsibilities weighing heavily on them, and maybe in a way the patient tries to control the anarchy by binging then purge. I003 continues to express that the language is important, and it is important for AN

and BN patients to identify their thoughts and feelings and express themselves fully. I004 explained, “the behaviours matter a great deal, but I do see them as a bodily communication rather than symptomatic behaviours”. I003 stated psychoanalysis “is an experience, a practice of speech. So, it’s all about language and discourse”. Participant I003 continued to say, “the goal is to make them talk more and more to the point that, the speech, you can somehow distill or capture that thing that cannot be put into words”. Overall, observing and analyzing the chaotic behaviour and/or environment can be useful, in addition to analyzing the chaotic language. According to several participants, putting words to actions seems to aid in the patient’s overall progression in treatment.

Theme 3: Treatment Limitations

Treatment limitations was a reoccurring theme that surfaced throughout the interviews. Gaps in treatment focused on CBT intervention limitations, short-term therapy, and the importance of not exclusively focusing on AN and BN symptoms. The data has revealed, if AN and BN patients are able to have control over their treatment, engage in a long-term specialized psychoanalytic treatment, and are able to build a healthy and secure relationship, then they can progress in treatment and achieve their goals. The data also revealed that the space in which the AN and BN patient can thrive is within a private practice setting, compared to a community- based mental health setting that offers short-term therapy.

Gaps in Treatment

While interviewing participants it became evident that other psychotherapeutic interventions, such as CBT, can be helpful add-ons to treatment. However, according to participants, an analytical approach to AN and BN treatment is going to provide more of an enriched clinical perspective and long-term support. I004 stated that “CBT is probably useful as

an adjunct, but you know it’s just not enough”. AN and BN patients would still be left hungry for more treatment. I004 continued to say that CBT “doesn’t get to the fantasy”, and thus is deemed inadequate as a primary treatment for AN and BN patients. There are significant gaps within therapeutic treatment, including but not limited to therapeutic approaches, duration of treatment, and third-party involvement such as the insurance companies. These gaps prevent the AN and BN patient from taking control of their session. For instance, CBT therapists are trained to have a standardized agenda for session, which suggests the therapist and not the patient has control over the session. Another example would be the inclusion of third parties, such as the insurance companies who have non-clinically trained agents directing the patient’s treatment plan, such as dictating the duration of treatment. All seven participants have stipulated the utmost importance of AN and BN patients taking control of their treatment, and their overall life. I001 highlighted the significance of the patient’s “ability to start taking control of the situation”, this included but was not limited to the reduction in the patient’s “emotional reaction to something that’s taking place”. For some AN and BN patients this sense of control and freedom to choose is possible. However, those who are unable to access private psychotherapeutic services unfortunately are subject to other barriers. The gap in this sense would include the limitations community mental health services exhibit, and therefore AN and BN patients who require long-term treatment are provided with short-term support leaving them hungry for more treatment.

Symptoms

AN and BN symptomology is significant to observe, evaluate, and treat. Although, AN and BN patients require more than a treatment that will focus primarily on the individual’s behaviours and/or symptoms. To effectively treat AN and BN patients, according to I004, requires “getting to these kinds of deep fantasies and what they represent”. Participant 1003

expressed AN and BN treatment involves “identifying the subjective structure and from there what emerges is what we call the direction of the cure, and the direction is toward finding the source of what is happening”. I001 adds, “the focus does not become primarily on weight itself”. There are so many components that are a significant part of AN and BN treatment, including the patient’s personality structure, psychic trauma, childhood experiences, as well as relationships with the self and others. A big part of the treatment is for the AN and BN patient to establish a healthy and secure psychoanalytic relationship in order to feel safe digging deep into the psyche.

Summary

The study fundamentally focused on the psychoanalyst’s experience treating AN and BN patients. Data was collected via interviews with seven psychoanalysts, which were audio recorded, transcribed, analyzed and interpreted using a thematic analysis. Interviews were approximately 20 to 30 minutes in duration. It was found that the data collected from the interviews were no different from the information stipulated in the literature review. Participants were able to elaborate on their experiences and provide education about their psychoanalytic approach that is relevant for the AN and BN population.

The findings uncovered three significant themes: the role of intrapersonal and interpersonal relationships in AN and BN treatment, emotional distress, as well as limitations to treatment. These three themes reveal the complexity, dedication, and commitment it takes for both the patient and the psychoanalyst to move forward in treatment. Interpretation of the data led to the conclusion that AN and BN treatment is a tiring and difficult process, which requires more than treating the patient’s symptoms. The psychoanalyst is regarded, not only as a clinical practitioner, but also an artist trying to find ways to treat the fractured AN and BN psyche.

CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS

Culminating the exploration and collection of data it is now time to lay everything on the table and discuss what was found. Prior to discussing the themes obtained from the data, it will be pertinent to discuss the interpretation of the findings. Interpretations that are provided are a product of the data obtained from interviews, the literature, and other professional networking engagements including but not limited to psychoanalytic supervision, has influenced the way in which the findings were interpreted. Interpretations are based on the researcher’s knowledge of the literature, perception, and understanding of the data. It is important to note that AN and BN patients do not fit perfectly into categories. Thus, the interpretations of the findings in and of itself is a flawed venture trying to comprehend and categorize the confusing and complex intricacies of the AN and BN patient, and ED treatment. Having said that, the psychoanalytical interpretation of the findings is a snapshot rather than a comprehensive understanding of the AN and BN patient, psychoanalyst’s experience, and AN and BN psychoanalytic treatment as a whole.

Summary of the Results

This psychoanalytic investigative study sought to explore a more specialized and long- term treatment for AN and BN patients. Rather than focus on the patient’s experience in psychoanalytic treatment it was deemed significant to explore the experience of the psychoanalyst, to understand the fundamentals and complex dynamics of the psychoanalytic relationship, and to comprehend the delicate psychic intricacies of the AN and BN patient from the perspective of the psychoanalyst. More specifically, the researcher and participant, in a sense, are on a quest to comprehend the phenomenon that occurs within the transference and countertransference with the AN and BN patient. Deconstructing and reassembling the

psychoanalyst’s experience treating AN and BN patients can give way to the harsh reality of what it means to live a life of otherness, what it is like to live as the “isolated other”. Whether the psychoanalyst may feel as though he/she/they are not sufficient as a healthcare provider, or the AN and BN patient feels as though they don’t fit in with society, living the life as a rejected or abandoned outsider takes a massive toll on the psyche. If the AN and BN symptoms are associated with insecure attachments that have led to the internalization of otherness, then the data suggests the patient is most likely to behave and live as the isolated other. In other words, the AN and BN patient will continue to act out their emotions, thus if they feel invisible they will act that out by restricting their food intake. The AN and BN patient brings the psychic trauma, including but not limited to living the life as the isolated other, to the session and acts out within the transference their insecure relationships.

The psychic baggage AN and BN patients brought to session was discussed with the seven participants recruited for this study. Participants not only provided their professional feedback and recommendations, but also provided vital information about their professional experiences and how they felt during the ED treatment. It’s curious, to what extent are psychoanalysts impacted by their AN and BN patient’s emotional baggage? What does this mean for the treatment, and progress within treatment? The research findings show that the AN and BN patient’s difficulty forming healthy and secure attachments with others and the self can influence the psychoanalyst within treatment. If the psychoanalyst can contain their countertransference, and analyze the transference, then the psychoanalyst would be able to take on a more objective position guiding the treatment.

Data collected from participants allowed for the in-depth exploration of what happens to the self and others when psychoanalysts and AN and BN patients come together in treatment.

Three important themes arose focusing on relationships, emotions, and gaps within treatment, will be interpreted and discussed in the following section.

Interpretation and Discussion of the Results

In this section the themes pertaining to intrapersonal and interpersonal relationships, emotional distress, and limitations within treatment will be elaborated upon. Discussions will emphasize what the interpretations signify, outline the importance of the themes, identify what the psychoanalyst can do to ensure their psychic stability, as well as discuss the ways in which psychoanalysts treat AN and BN patients.

Theme 1: Relationships

The data collected provided enriched information concerning interpersonal dynamics between the AN and BN patient and others - including but not limited to the psychoanalyst - as well as a relationship with the self. The ways in which AN and BN patients interact with others – such as the dynamic between the patient and psychoanalyst in session, as well as the psychoanalyst’s experience and countertransference - all play a significant role in structuring and executing the psychoanalytic treatment.

Mother

The patient’s relationship with their mother seems to play a vital role in the onset and maintenance of AN and BN. The cold, distant, and emotionally unavailable mother during the prepubescent stage of development has left the AN patient to internalize the disconnect between the self and idealized mother. The AN patient begins to assume responsibility for the disconnect, feeling as though they are not “good enough”. The more in which this is internalized, in addition to other psychic traumas, can compel the AN patient to unconsciously act out their neglect. In other words, if they are not deemed “good enough” then they do not need to eat enough, as if

they are unworthy of basic necessities such as food.

In the case of the BN patient, they are more likely to experience “too much mother”,

where the mother may be overly involved and/or strict. The chaos the BN patient can experience by having an overly involved mother may trigger an unconscious acting out, as an attempt to rid the mother. Since the mother takes on a very controlling and micromanaging role during the prepubescent and pubescent stages, the BN patient attempts to rid the mother by ingesting and vomiting the mother. In other words, the BN patient who experiences a loss of control will attempt to control primitive behaviours such as eating.

Father

Aggression from the father is another serious component that can be the catalyst for the onset and maintenance of many different mental illnesses, including but not limited to ED. For the male AN patient, the estranged relationship with the father during the pubescent and adolescent stage of development plays an important role in the way in which the patient views himself/herself/themselves. Physical aggression, psychological abuse including body shaming, and forms of emotional and societal/cultural emasculation by the father, are a few factors that aid in the AN patient’s negative fabrication of their self-concept. The female AN patient may internalize feeling as though she/he/they are not good enough for the father. The male AN patient, in opposition, may feel as though he/she/they are too feminine for their very masculine father. In this case, the male AN patient may be, in an analytical sense, full of the father and thus refuses to eat. “Too much” father, in the case of the male AN patient, enables primary restricting behaviours with the possibility of secondary binging and purging behaviours.

Family Problems and Interpersonal Relationships

Complicated, toxic, and/or abusive family dynamics, including but not limited to divorce 94

and parenting styles, are some of the problems families can face that can perpetuate the AN and BN patient’s symptoms. Participant I005 discussed an AN case concerning a 12-year-old female patient who felt rejected by her parents. The more the child internalized her feelings of emotional neglect and rejection the more in which she refused to eat. Refusing to eat, in the child’s mind, allowed her to feel in control, to be seen, and get the attention she was looking for. A complex analytical interpretation may include, the more in which she wanted to be seen resulted in her not being seen by her parents, and thus acting out the feeling of not being seen by not eating induced in the parents the need to see her. I005 explained, there was an association between the child’s feelings of emotional neglect by her parents, and the exacerbation of her symptoms.

In the case of the 12-year-old AN patient, it was clear that the child was desperately seeking the love and approval from her parents. It was clear, from participant I005’s perspective, that the child’s AN symptoms worsened the more in which she felt neglected. I005 disclosed that the AN patient was referred a children’s hospital where she would receive inpatient care, along with family therapy and education. According to I005, the AN patient was glad her parents were by her side and actively supporting her during her treatment.

It may or may not have been the case that the parents felt burdened, to some capacity, by the additional needs and resources the 12-year-old child needed, while simultaneously caring for other children in the home. Even though parents can feel stressed, which is not atypical because parenting can be overwhelming, it is the parent’s obligation as caregivers to provide their dependents with the necessities, including but not limited to: food, shelter, clothing, affection, as well as a sense of belonging. Based on the cumulative research, and the data collected from participant interviews, it is evident that the way in which parents treat their children is associated with the way in which the child builds a relationship with the self and others. If parents are

withholding, neglectful, and/or abusive, children will internalize the toxicity and construct a sense of self that is withholding, neglectful and/or abusive. Thus, children that grow up to become adults who have built a negative or abusive self-concept are most likely to find companionship with those who preserve the neglectful, withholding, and/or abusive relationship. In other words, it is not uncommon for an adult female, who felt emotionally neglected by her father and/or mother, to unconsciously seek out emotionally neglectful platonic and/or romantic relationships.

Psychoanalytic Relationship

The data obtained from participant interviews reveal that a nurturing, active, and flexible psychoanalytic relationship aids the ED treatment itself as a fundamental building block. In other words, the psychoanalytic relationship is the vital foundation the treatment is based on, which guides the treatment insofar as to help AN and BN patients build trust and comprehend what a secure relationship looks like. Do not mistake the nurturing, active, and flexible psychoanalyst as an individual who does not have boundaries. Just because psychoanalysts like I004 allowed her AN patient, who was severely anorexic and suicidal, to text her and/or call her after work hours does not mean I004 does not stipulate specific and clear boundaries with her AN patient. Boundaries, articulated by I004, would include not calling and/or texting past a certain time in the evening unless it was an emergency. A wider frame allows psychoanalysts like I004 to take on a more nurturing and active role, while at the same time maintaining their boundaries and thus maintaining the structure of the treatment. All interactions, even after-hours interactions, can be analyze and interpreted as part of the treatment. Psychoanalysts, like I004, are trained and mindful of the traditional neutral psychoanalytic approach to treatment. However, according to I004, her AN patient would be dead if she took on a neutral psychoanalytic position.

Psychoanalysts are trained to meet the patient where they are at, which includes rolling with the resistances by taking note of the AN and BN patient’s fantasies and associations. ED treatment is very challenging work that requires patience, understanding, and empathy. Participant 1003 expressed that the first year of treatment, especially with AN and BN patients, is about getting to know each other and building the psychoanalytic relationship.

Theme 2: Emotional Distress

Maladaptive behaviours, including restricting, binging, and purging, are ways in which AN and BN patients act out their emotions. From a psychoanalytical perspective, BN patients put in the toilet the essence of their emotional distress. The inability for the BN patient to fully articulate their psychic trauma and emotional distress stays buried and is expressed through binging and purging. In other words, the BN patient is not using their mouth to articulate how they feel or what they think, rather it is covered up by food, vomit and/or faeces. For the AN patient, a sense of abandonment is internalized and acted upon by way of restricting their food intake. The more in which an AN patient felt invisible, neglected, rejected, and/or abandoned, especially if this were to occur early in life, the AN patient would most likely continue to unconsciously act out the aggressive attack by refusing to eat. AN and BN patients are full of emotion that seems to be weighing them down. Aiding AN and BN patients in establishing a platform to converse with their circle of care, as well as learn how to identify and articulate their thoughts and feeling accurately will help AN and BN patients reduce their problematic behaviours.

Anger

Anger is an interesting emotion. People either tap into their aggression - via fantasy, articulating their anger, and/or aggressively acting out their rage – or actively attempt to deny

and burry their anger as not to induce any intrapersonal or interpersonal conflicts. Majority of participants, if not all, discussed that their anger and/or their patient’s anger can negatively impact the psychoanalytic relationship and overall treatment if not analyzed sufficiently. For instance, it is the role of the psychoanalyst is to contain one’s own countertransference insofar as to be able to identify, analyze, and interpret what is going on within the transference. It is also the role of the psychoanalyst, to seek supervision, consultation, and/or one’s own analysis as a means to unpack what was contained within the patient’s session. Anger is an emotion that is neither deemed “good” nor “bad”, rather anger just is. It is the role of the psychoanalyst to interpret and guide the AN and BN patient in identifying and expressing their anger in a healthy manner.

Abandonment

AN and BN patients have a tremendous fear of abandonment. It is not uncommon for an AN patient to disconnect and dissolve relationships prematurely. This is typically done out of fear that the other person would abandon the AN patient, which can induce a very damaging self- concept and intrapersonal relationship. Participant I007 explained that she was extremely fearful of how close her AN patients were to death. Severely low body mass and suicidality are a couple of ways AN patients unconsciously act out their internalized feelings of abandonment. For the AN patient the attack on the self does not stop at food restricting behaviours. The AN patient is likely to continue the unconscious attack on the self by way of guilt. For instance, the AN patient may believe that people leave because of some flaw or limitation, and/or the individual is a bad person who then intentionally or unintentionally hurts other people. As guilt, a sense of abandonment, and other thoughts and emotions arise, both the AN and BN patient can attack the self in very harsh and damaging ways. The AN patient may associate their feelings of

abandonment with feeling invisible, where the individual then acts out this attack on the self as a means for the body to reflect the mind. The AN patient engages in the attack on the self – an unconscious wish to be invisible and ultimately destroy the self out of guilt – by way of, including but not limited to intense food restricting behaviours, self-harm, and suicide. The BN patient, on the other hand, is more likely to cover up their desperate need for love and attention. Binging on food, and even promiscuous sex could seem like advantageous substitutes for love and attention, but the pleasure obtained by engaging in such risky behaviour can be dangerous and is short lived. The BN patient craves the love and affection, that can at times be replaced by food, but the harsh realization of their sense of abandonment leads to the unconscious acting out via purging and/or defecating. The BN patient attempts to rid themselves of their internalized objects, such as their mother and/or father, in hopes of ridding themselves of their emotional pain. Abandonment for the BN patient can induce a desperate need to be loved - this can be hindered by an unconscious loathing of the self – which is associated with the increased risk of engaging in unprotected and promiscuous sexual encounters.

The art of treatment, and sometimes the most uncomfortable aspect, is to sit with the AN and BN patient in their pain. By allowing AN and BN patients to sit with their painful thoughts, feelings, and experiences enables them to get in touch with the psychic trauma that need to be processed. Sitting with the patient involves allowing the patient to identify and articulate their pain, elaborate on their associations and fantasies, and maybe develop a theory or interpretation independently. It is not uncommon for AN and BN patients to avoid their minds, such as talking about superficial topics in session. Psychoanalysts typically note this behaviour with the patient, analyzing the defence, and gently redirect the AN and BN patient back to their mind. It is certainly “painstaking” and difficult in many ways to sit with AN and BN patients in their pain.

However, AN and BN patients require guidance concerning re-learning or learning how to identify and sit with difficult emotions, which is the basis for unpacking such distressing thoughts, feelings, and experiences.

Distrust

Erik Erikson believed the ability to trust is established during infancy (Knight, 2017). The infant is completely dependent on their caregiver, typically the parent, where trust is built based on the parent’s ability to balance the infant’s pleasure and frustration systems. For example, there are times in which infants become fussy, whether changing a diaper or trying to place the child down for a nap, it is the parent’s responsibility to balance the infant’s ability to self-sooth and when the nurturing parent is needed. In other words, it is not uncommon for parents to allow their infant to self-sooth during nap time, especially if the child has a dry diaper and is fed. The child begins to build trust in their self, learning how to self-sooth and fall asleep on their own, and comprehending that their parent are available when in need. Distrust seems to be a learned phenomenon where the balance of pleasure and frustration are skewed, and the infant experiences more frustration than pleasure. For instance, the cold, distant, and/or emotionally unavailable mother induces in the child the desperate need for the mother. The ongoing neglect of the infant’s needs can leave the infant feeling as if they are alone. The mother and/or father’s inability to bond and fulfill the needs of the infant - as well as allow the infant to learn and self-sooth independently - significantly impacts the infant’s future intrapersonal and interpersonal development. How can the adult child learn to trust others if the inner child exhibits distrust towards the parent(s)?

Trust is earned and built within session over time, it is not given up by the AN and BN patient so easily and immediately, which seems to be another contributing factor in the surfacing

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of certain resistances to treatment and the psychoanalytic relationship. If imbedded within the treatment is the psychoanalytic relationship as a fundamental building block - which involves balancing the delicate relationship between pleasure and frustration within session – then there is no mystery as to why AN and BN patients would feel triggered. For example, there may be times in which a psychoanalyst will articulate an interpretation, in a sense feed the AN and BN patient, in order to help the patient build insight. Other times psychoanalysts may withhold certain interpretations, which can be a difficult process for the AN and BN patient, to allow the patient to self-sooth and build their own insight. Without establishing a strong and secure psychoanalytic relationship it would be difficult for the psychoanalyst to challenge the patient’s resistances, fantasies, and/or allow the patient to get angry insofar as to guide them in building their sense of self.

Chaos

Imagine losing control of a car. The feeling of not being able to do anything, feeling helpless as the car moves without purpose to an unknown destination. Psychoanalytically speaking, this loss of control can also occur in the psyche. Sometimes the pressures from life can pile on, and for BN patients the ongoing pressure that is piling on the BN patient’s plate can induce a feeling of losing control. The binging behaviour is an unconscious representation of the psychic trauma, the loss of control or chaos the BN patient experienced that was denied. The purging and/or defecating is a way for the BN patient to regain a sense of control, and continue to deny the psychic trauma, to sooth the chaos in the BN patient’s mind. Attempting to rid of the psychic trauma by way of vomiting and/or defecating is short lived. Once the BN patient is triggered, the traumatic associations became activated in the psyche via intrusive thoughts and/or nightmares, the pressures pile on, and the BN patient increasingly feels out of control.

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The BN patient acts out the chaos within the psychoanalytic treatment. For instance, attendance is a significant part of the frame and overall requirement for treatment. BN patients may show up late to session or no show, which is an unconscious way of acting out the feeling of losing control. They may feel forced to go to treatment, for whatever reason, and thus act out a sense of control by showing up late to session, staying silent throughout the session, or not showing up to session. The psychoanalyst may also sense this as well, within the transference and/or countertransference, feeling disorganized and/or having difficultly thinking analytically. This is another example of how important it is for the psychoanalyst to contain their thoughts, feelings, and experiences mutually exclusive from the AN and BN patient.

When psychoanalysts are unable to contain their thoughts, feelings, and/or experiences in session, the psychoanalyst and the patient can fall victim to an enactment. In this case, the psychoanalyst is in a sense acting out similarly to the patient. Thus, what is occurring within the transference is not adequately analyzed, since the psychoanalyst’s countertransference is essentially interfering with the treatment. It is not uncommon for psychoanalysts to fall into the trap of an enactment, it happens, we are all human. However, it is the responsibility of the psychoanalyst to ask for support when needed, such as seeking supervision, consultation and/or their own psychoanalysis, especially if the treatment has plateaued. The enactment can be discussed and analyzed within the transference if and only if the psychoanalyst is able to recognize the issue.

Theme 3: Treatment Limitations

There were significant limitations addressed during the interview process, which included a comparison between a CBT approach to ED treatment and a psychoanalytic perspective. The medical model suggests clinicians should focus primarily on the AN and BN patient’s symptoms,

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and other factors are secondary. Through the rigorous exploration of the psychoanalyst’s perspective and overall experience treating AN and BN patients, it was unanimous that psychoanalytic treatment fundamentally involved exploring various components of the individual, including but not limited to: personality structure, childhood experiences, and symptoms. This section will focus on the limitations within ED treatment as outlined within participant interviews. Additionally, this section will outline the limitations that have manifested during the overall research process.

Gaps in Treatment

Not only are there gaps within treatment, but there are also gaps within the mental health system. In other words, community-based treatment programs and insurance companies are structured in such a way as to offer short-term therapeutic support. Short-term therapy may be useful for individuals struggling with situational concerns, such as a job loss. However, AN and BN treatment require long-terms therapy that focuses on all aspects of the individual, and not just one’s symptoms. Long-term treatment is necessary for AN and BN patients because it takes time for patients to build trust and establish a psychoanalytic relationship, as well as explore and elaborate on their thoughts, feelings and experiences. Anything less than long-term treatment for AN and BN patients would be doing the patient a disservice.

Symptoms

The essence of long-term treatment, in addition to establishing a secure psychoanalytic relationship, involves the exploration of the patient’s psyche. The AN and BN patient’s mind can be a difficult place to explore for both the patient and psychoanalyst. However, constructing a safe, non-judgmental, and open space to freely express oneself will hopefully support the AN and BN patient in feeling comfortable enough to able to present their vulnerable self in session.

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To be vulnerable with someone does not come easy for a lot of people. So, for the AN and BN patient it is essential for the psychoanalyst to allow and support the patient in fully expressing their mind, such as the desire not to eat and/or the fantasy to die. Psychoanalysts are not only responsible for conducting risk assessments - to determine if AN and BN patients are at risk for harm - but are also in a position to guide the patient in exploring their fantasy to escape or die. Digging deeper will allow the psychoanalyst to uncover a more holistic perspective of the person and unveil the associations that keep the AN and BN patient stuck. Identifying the psychic trauma(s) and bringing the associations to the forefront of consciousness enables the AN and BN patient to, over time, process and release what is keeping the patient stuck. In addition to building insight into who the patient is as a person, not just a patient but an authentic person, allows for the individual to process situations differently, identify potential opportunities that may have been overlooked previously, and thus make different choices. Processing psychic trauma and building insight takes time and requires the guidance of a skilful psychoanalyst.

Discussion of the Conclusions

The results from the data collection, from both participant interviews and the literature, unveiled that the psychoanalyst’s perspective was in accordance with the information dictated in literature review in Chapter 2. AN and BN patients require a specialized and long-term treatment that focuses on the driving factors behind the symptoms, learn how to establish secure platonic and romantic relationships, as well as find a sense of self. The literature review presented many different psychoanalytic theories that can account for why an AN or BN patient would remain stuck, along with other theories including the biopsychosocial perspective and parenting dynamic that played a role in the onset of an ED. However, participants were able to go into detail about their experience working with ED patients, as well as their psychoanalytic perspective and

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interpretations. The literature was able to provide a general overview of the psychoanalytic theories and contributing factors associated with AN and BN. Nevertheless, it was the information obtained from participants that allowed for a more in-depth exploration of ED psychoanalytic treatment, and the AN and BN psyche.

The problem concerning AN and BN standardized treatment, as represented by the CBT approach, was also discussed in the literature review and interview process. Similar to what was outlined in the literature review, participants stipulated interventions like CBT are helpful adjuncts to psychoanalytic psychotherapy for AN and BN. According to participants, even though treating AN and BN patients using psychoanalytic psychotherapy can be “painstaking”, and can ignite feelings associated with burnout, there seems to be great reward in treating AN and BN patients. Both the psychoanalyst and patient have an opportunity to learn about themselves, and work as a team to break down the barriers associated with AN and BN.

The findings also revealed that treatment for AN and BN require a scientific and somewhat artistic approach. Psychoanalytic treatment involves establishing a fundamental structure, such as the frame that aids to build the foundation of treatment that is the psychoanalytic relationship, which helps to foster intrapersonal and interpersonal insight. In other words, AN and BN patients will attempt to push against the frame and/or act out, which is all part of the treatment. The AN and BN patient acts out what cannot be articulated. Thus, it is the psychoanalyst’s duty to use specific techniques - such as free association, dream analysis, and learning to listen with a third ear – as a means to guide the treatment and balance gratification with frustration.

The psychoanalytic treatment approach can be daunting to the psychoanalyst, which many participants have mentioned. It is especially important for psychoanalysts to be aware of

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what manifests within their countertransference and assess if the psychoanalyst and the patient are involved in an enactment. For the psychoanalyst, understanding the difficult components of the AN and BN patient’s mind can also be a difficult process where certain defences may safeguard certain psychic traumas. Therefore, it is vital for the psychoanalyst, especially when working with AN and BN patients, to seek supervision or consultation, and personally engage in one’s own psychoanalytic treatment to strengthen the psychoanalyst’s container.

Based on the findings, it is also worth noting that not many psychoanalysts work with AN and BN patients providing specialized ED treatment. Having that said, not all psychoanalysts that are trained in providing psychoanalytic treatment are competent and/or skillful in providing AN and BN treatment. I003 specifically noted that psychoanalytic ED treatment is not for the newly certified psychoanalyst. Rather, AN and BN psychoanalytic treatment requires a more in- depth understanding of AN and BN, as well as practical knowledge on how to approach ED treatment. Training also takes time, patience, and involves a process of introspection.

Limitations

Literature

With every study there are limitations that must be addressed. Majority of the literature found pertaining to psychoanalysis, AN, and BN predominately included samples of white adolescent females and/or young adult females (American Psychiatric Association, 2013; Lingiardi & McWilliams, 2017). There was limited research pertaining to the development of AN and BN within the male population, as well as other diverse populations (Crisp, 2021; Iwajomo et al., 2021). Additionally, there was very little information about the AN and BN male personality structure. The research process yields limited literature pertaining to the personality structure and onset of AN or BN in male patients from the psychoanalytic perspective.

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Additionally, there was very little information regarding the analytic dimensions of AN and BN within diverse cultures. Majority of the information obtained during the research process predominately focused on the female population.

With regards to socioeconomic status, there was significant research to suggest that AN and BN ailments are present in “middle to upper class” societies (Busiol, 2021; Lingiardi & McWilliams, 2017). However, recent studies have revealed that individuals of various socioeconomic statuses can exhibit AN and BN symptoms (Mulders-Jones et al., 2017). Hopefully future qualitative research will include the exploration of the AN and BN male psyche and attempt to understand the development of ED from the perspective of the male, and culturally diverse patient.

The Research

Recruitment

The recruitment process was challenging since many psychoanalytic practitioners from the TPS&I and TICP have not treated AN or BN patients. It was interesting to note that majority of psychoanalysts that held a “retired” membership had worked with AN and BN patients. However, not many retired psychoanalysts were willing to partake in a 20 to 30 minute interview. Upon reflection of the recruitment process, it has become clear that there are not many healthcare providers who work with AN and BN individuals, and even less who treat using psychoanalytic psychotherapy. Having that said, there seems to be a huge gap in resources, with specific reference to psychoanalytic treatment for the AN and BN populations in Canada. Not many healthcare providers, including psychoanalytic providers, have sufficient training in treating AN and BN patients. Few healthcare providers in general are willing to treat individuals with complex ailments. Therefore, after briefly speaking with members, affiliates, and guests of

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the TPS&I and TICP associations it is obvious there is no sufficient research that allows for a rigorous understanding of the AN and BN psyche, as well as explore the experience of AN and BN psychoanalytic treatment through the lens of the psychoanalyst. It can be argued that this study is part of a vital exploration of the AN and BN psyche, and what it means to treat those who struggle with AN and BN.

Assumptions

It was assumed that participants were truthful in sharing their experiences. Credentials pertaining to licensing was validated by the provincial licencing boards. However, the participant’s level of training, and their history in working with AN and BN patients cannot be substantially validated. Therefore, it was assumed that participants are forthcoming and honest with their answers during the interview process.

One limitation involved submitting to certain assumptions. Since this study focused on the psychoanalyst’s experience treating AN and BN patients the researcher had no control over what was discussed, or how to verify what the participant was saying was true. Another assumption, based on the literature, was to assume that AN and BN primarily surfaced following a psychic trauma(s) that had occurred prior to or at the time of puberty (Lingiardi & McWilliams, 2017; Wooldridge, 2017ab). It is possible that an individual’s biological makeup, along with the psychic trauma, can also influence the onset of AN and BN (Christian, 2020; American Psychiatric Association, 2013). It is clear there are many factors that can influence the onset and maintenance of AN and BN. However, psychoanalysts do not have a comprehensive understanding as to all the factors that can influence AN and BN patients. Rather, more information is revealed the more in which AN and BN patients are able to be vulnerable and forthcoming with their psychoanalyst.

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Recommendations for Future Research

Recommendations for future research would include more in-depth qualitative research, as well as quantitative research focusing on psychoanalysis as an effective approach in clinically treating mental illness. Outside of the psychoanalytic community there is not much research focusing on psychoanalysis as an evidence-based, scientific, and overall acceptable therapeutic intervention. More specifically, it would be interesting to quantitatively analyze and compare the effectiveness of the psychoanalytic approach to AN and BN treatment to other treatment modalities, including but not limited to CBT and psychotropic medication.

A second recommendation would include a psychoanalytic perspective on male AN and BN patients specifically. There is little to no information about the male AN and BN personality structure, childhood traumas associated with ED, particular resistances including defence mechanisms, compare and contrast parenting styles of female AN and BN patients with male AN and BN patients, as well as comprehend intrapersonal and interpersonal relationships. The male AN and BN patient should not go unnoticed, this will perpetuate the vicious cycle. Treatment for the male AN and BN patient may not be different from treating female AN and BN patients. However, it is necessary to comprehend the complex and delicate intricacies of what it means to treat a male AN and BN patient. This process requires a scrupulous investigation of what it is like to live the life of a male AN and BN patient, as well as what it is like for psychoanalysts to treat male ED patients.

Lastly, it is vital to embark on a multilayered cultural exploration of AN and BN, focusing on various aspects of culture, including but not limited to age, gender, race, religion, socioeconomic status, and sexual orientation. The literature and all participant interviews were based on middle to upper class White female AN and BN patients. There was one male AN

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patient that was discussed during the interview process. As previously addressed, there are a multitude of factors that contribute to the onset and maintenance of AN and BN, which is not limited to middle to upper class white females. A psychoanalytic cultural perspective focusing on AN and BN is a vital component concerning the ongoing understanding and treatment of complex mental illnesses. The psychoanalytical school of thought is vast and includes Western and Eastern perspectives. Thus, it is imperative that future research center on a more culturally sensitive ED research study.

Conclusion

Overall, AN and BN are complex mental illnesses that require a specialized and long- term treatment. Psychoanalysis provides a basis to build a healthy and secure psychoanalytic relationship that will allow AN and BN patients to explore their mind, and express themselves authentically within the world. Putting words to the maladaptive behaviours, more particularly comprehending the AN and BN patient’s psychic narrative, will allow for the psychoanalyst and patient to grow together, build insight, and progress.

Let’s not forget about the psychoanalyst, and what it takes to treat AN and BN patients. It is not uncommon for psychoanalysts to be triggered in some capacity, to the point where they may unintentionally engage in an enactment. It is important for the psychoanalyst to be soft with the self, seek supervision or consultation, as well as seek one’s own psychoanalytic treatment. Ensuring a healthy balance between the psychoanalytic work that needs to be done and self-care is an ongoing battle. It is imperative that the psychoanalyst maintain the balance between treatment and self-care to ensure their container is secure, insofar as to appropriately and respectfully treat vulnerable AN and BN patients.

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