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Second international conference on eating disorders, New-York, April 1988.

    According to modern opinion, anorectic patients should not be prescribed a classical psychoanalytic cure: psychoanalysis in a strict sense, is said, by most specialists, to be ill-adapted for this kind of difficult patients. Rewiewing the freudian writings, we may find some notations on Anorexia Nervosa, mainly described as an hysterical affection, but nowhere there is to be found any report about the cure of such patients.

Since the now-classical description of GULL and LASSEGUES is absent from the experience transmitted by FREUD, we must rely on his successors or on our own therapeutic experience.

First, according to most practionners, any long-term psychotherapy meets with difficulties. We'll try to have a look on minimum conditions to begin and maintain a real therapy. Most of our experiences with anorectics show a high rate of drop-outs in quite a short time. Some of these patients come with an apparently authentical desire for therapy, follow a few sessions and disappear at short or without notice. They can either give up hope for any therapeutical solution or resume the therapy with another therapist, as if the person of the therapist were indifferent. This allows the anorectic to avoid any affective involvment with her therapist, by focusing on a disembodied, and so ineffective, medical help. The "as if" therapy acquires a meaning and an importance in itself, losing touch with external reality and maybe more dangerously with psychic reality, namely the Unconscious. The Ego leads the way in a humdrum which may persist for years or stop on the first occasion (illness, holidays, or any event interrupting the course of the therapy).

 The main feature of these therapies is the resistance to change; the patient may conscienciously tell of all her life or remain silent, nothing moves. The cure may turn short as it is satisfying neirther to the therapist, neither to the patient. The symptoms persist or even get worse. Maintaining such a therapy makes the therapist uneasy: either he can tell the patient of all his feelings about the uselessness of the whole cure, forfeit any hope and risk a mistake by an over-pessimistic view, thus compromising all past and future work, either he can maintain a meaningless cure for years, hoping for something to happen, unjamming the psychic apparatus, and permittinga release of the unconscious. This may never happen, in this therapy, because of the death-dealing interaction of the transference and counter-transference. Or, finally, the therapist may be tempted to act on a more active, in fact reactive way, and to jostle the defenses of the anorectic, waiting for a positive change. All these solutions are to be considered as the equivalent of an acting-out from or for the patient.

Another type of failure exists for a beginning therapy, that of extreme transference, in fact falling in love with the therapist, whatever his gender. Interpreting the massive transference, in usual way, at the outset of the therapy goes against all the patient's feelings as she isn't prepared in any way to the dynamics of the cure. Most of those patients can't bear the neutrality of the therapist, even less his rebuffal, and stop the cure with ressentment. The ultimatum can be heard as "Either you stay away and there's no point in engaging a therapy or you share my feelings and we can pursue my healing". Any of those solutions immediatly forfeit any hope of pusuing the cure.

From the intra-psychic point of view, the anorectic way of life represents a pathologic equilibrium, pathologic in a sense that most of the unconscious is kept at large, thus shrinking the whole life of the patient; and pathologic in a sense that life is threatened in his continuity, death being the ever-present way-out. The death and life instincts act on separate way where life instinct preserves the subject in his life but prevents any evolution and death instinct constantly threatens his survival but goes on the way of change. This equilibrium is maintained with an important energy output, so any therapeutics will go against massive defenses. To counter the therapeutic threat, the transference relationship is perverted in an archaic way. Instead of beginning a love or hate relationship with the therapist, this one is used on the oral mode: swallowing or spitting him.

Massive transference at the outset of the therapy must not be understood as a classical transference: a love/hate realtionship; in fact this reaction bears the mark of the oral stage and the object-relationship involved in the term transference may be unappropriate. Incorporation and identification are nearer from our clinical experience. Let us remind that, according to FREUD, the primary identification represents "the most original form of an affective bind to the object" earlier than love. This immediate relationship, deeply related to the image, may be understood as a print, a "Prägung" in the sense of Konrad LORENZ. This kind of extremely archaic mecanism may explain the massive appearance of this pseud-transference. Some very un-typical features are to be noticed: despite the extremely affective relationship, nothing moves as the transference is difficultly interpreted an more, nothing can be elaborated on it. Symbols and specially talk, can't act on this transference, the talking-cure is impotent in resolving the transferencial problem.

In a more pragmatic way, the therapy of the anorectic is to be focused on maintaining the cure itself as the peculiar anorectic transference can be considered as extremely hostile, aiming for protecting the statu-quo. Whatever the way used, manifest hostility or apparent positive transference, both look for nullification of our work. Both block any evolution in the therapy as they put the therapist in an impossible position: acting and threatening the cure or do nothing and risk physical or psychic death of the patient.

A lightly seductive attitude, howewer staying at the edge of neutrality, from the therapist can catch the anorectic in her own game, making a later analytic work possible. A more seductive or friendly attitude can both avoid rejecting the patient with massive transference, pursue the cure, or create a bind with an hostile patient. This seductive attitude can be considered as necessary, howewer sterile for itself, as it opens the way for a more constructive approach. For this, psychoanalysis first can't be used, as breaking the classical neutrality would forfeit his essence, but an analytic-inspired therapy can be considered, in those difficult cases, as the pre-psychoanalysis, necessary to begin the analytical process.