EATING DISORDERS AS A BIO-PSYCHO-SOCIAL DISCONNECTION IN THE LIGHT OF A GESTALT APPROACH
Eating disorders (mainly bulimia, anorexia, and binge eating) – are severe disorders of eating behaviour which represent themselves in the disconnection between the biological need for food and the psychological experiencing of the need for food.
The disconnection between the biological need for food and its psychological experiencing can be described in the following way: biologically our body needs to consume a certain amount of nutritious substances, at the same time psychologically we don`t feel a need for nutritious substances in themselves, but we experience hunger, satiation, craving, pleasure, disgust, etc. For example: biologically our body might need protein. As long as protein is a chemical phenomenon we cannot want (psychologically) to eat protein. Psychologically we can want to eat a piece of meat or an egg. The biological needs represent themselves in psychologically experienced desires, preferences, and behaviour: when we are hungry – we eat, when we are satiated – we stop eating, we make our choices regarding “what to eat”, “where to eat”, and so on. It is crucial for our topic of eating disorders as a bio-psycho-social disconnection to see the boundary between the realms of “substances” and “every-day-life things” we deal with in a routine way, and to describe them with the non-specific, every-day-life language. So, proteins and carbohydrates belong to the “chemical realm”. We have some knowledge about them as chemical substances but we don’t experience them as such. What we do experience – is food: a steak, eggs-over-easy, a glass of warm (or cold – if you prefer) milk, etc. The chemical substance represents itself in the things, which can be objects of our direct attention – which is the food itself.
Normally the correlation between the biological needs and their psychological representations exists out of our consciousness: being thirsty we are looking for a glass of water and don’t think about the water-and-salt balance. What is even more important - we don’t need to know that this balance exists. This last point is essential: the connection between the biological needs for food and their psychological experiencing is not supposed to be part of our awareness. This crucial fact determines the severity of the eating disorders: in the first place on the level of individual functioning it is a disconnection between two realms – biological and psychological; in the second but more important place – it is a broken connection which is supposed to be automatic and is not supposed to be the focus of our conscious attention. This provides the explanation why the treatment of eating disorders is so time-consuming and so often producing only temporary results.
Another aspect of eating disorders is related to the social side of eating. Unfortunately we have to consider one more disconnection – that is between the consumption of food and the social environment and the social circumstances for eating. This theme is not simple to consider because we have to touch the issue of “social norms” (which are definitely relative) on one side, and the results of the social-historical development - on the other. Here I dare to say that some aspects of eating disorders are consequences of the person’s disconnection with some social values and routines related to eating. Let’s start with the list of socially determined aspects of eating which I consider healthy:
-To have an approximate eating “schedule”;
- To enjoy tasty food;
- To eat at the table;
- To use “real” plates, forks, spoons, knives (not plastic or paper);
- To set the table in an aesthetically pleasing way;
- To enjoy eating together in company;
- To appreciate an opportunity to eat tasty food in a beautiful environment together with pleasant people
- To eat with an appetite;
- To prefer not to eat when not hungry.
I consider the following aspects of eating to be unhealthy:
- To eat in a hurry in inappropriate places (in a subway, or in bed – if you are not sick);
- To eat while pursuing other activities (e.g. reading, watching television, at the computer);
- To eat what is «good for you» regardless of whether or not you like it.
Our urban everyday life is a real challenge. Not having enough time, people eat in the car, the subway or on buses, very often just out of their hand. The “ocean” of snacks that are available sweeps over the practice of eating regular meals. The fact that the North American (including Canada) portion in restaurants is gigantic has been discussed already many times. Even a mindful attitude toward food and eating has lost an important link – that of the pleasure associated with eating. People today are obsessed with the idea of healthy food (low fat, low salt, low sugar), and this layer of knowledge does not allow them to enjoy the food directly, and closes the way for intuitive preferences. (By the way, for instance, very often those who appreciate the good taste of food are not into using much salt). Summarizing the social messages about food and eating, we have to admit that they are not positive and healthy. They are: “It is OK to neglect the process of eating” and ”Don`t trust yourself.”. These messages do not lead directly to eating disorders, but when the sphere of eating becomes problematic for the person this social set starts working very strongly against the person.
It is appropriate to remind ourselves that historically human eating is a social action. A contemporary tradition in which the family eats together as part of a celebration (e.g. a wedding, or a funeral) is an indirect confirmation of this idea. When we eat together we share not only a common space and time. We also experience similar taste sensations, we commit the same physical movements (chewing, swallowing, etc.); even the fact that we suspend the conversation during eating is significant – it works positively for our trust for each other (that is why “a business lunch” is a successful way of negotiating a deal!). In relation to eating disorders I have to mention that laboured eating in public is a very frequent symptom of an eating disorder, and – on the other hand – one of the earliest signs of recovery is the ability to eat in company without any other signs of the disorder.
In summarizing I would like to say that when dealing with an eating disorder we have a situation when: 1) eating is not an adequate response to the body's need for food; 2) the body's need for food does not reflect itself in eating behaviour; 3) eating does not connect the person with others. The psychotherapeutic consideration I am going to move to below demands one more observation I have made while working with the eating disordered population: these clients very often have complicated relationships, in particular – they experience real predicaments in setting psychologically well-balanced working distance with partners, or with relatives. An accurate description for this kind of relationships is that “she/he is stuck in this relationship”. This last statement may work as a good stepping stone for analyzing eating disorders in the light of Gestalt-therapy because it helps us to ask a couple of really Gestalt-questions: 1) what are the characteristics of the “self'' boundary for the person with ED? and - 2) what is the way of contacting that this person implements?
Presumably this boundary does not work as an “in-and-out post”. It lets in unlimited food in the case of binge eating, it lets in specific foods in an amount which is not supposed to be assimilated – in the case of bulimia, and it does not work as an entrance in the case of anorexia.
It is clear that the cycle of contact does not work. Craving as a specific state which is typical for the clients with ED, is not analogous to the desire which the person may have regarding what, when, and where she/he wants to eat. Nevertheless this choice is supposed to be made at the stage of the pre-contact. The pleasure and joy related to the eating process which pertains to the stage of contacting – are omitted as well. Post-contact never comes: a bulimic person misses the moment “it’s enough” and a bit later - like remembering suddenly – removes abundance (excess) out of the body. Therefore a bulimic does not have a chance to experience sufficiency. The same may be said about a binging person: she/he does not receive the inward signal “it’s enough”; therefore the post-contact is missed also. (I am deliberately not commenting on cases of anorexia. No doubt this disorder can be described in the same Gestalt terminology. However this disorder is not an analogy for binge eating and bulimia. Anorexia is much more dangerous and has more existential aspects. This article is short, and I would like to avoid over-simplifying). Instead of anticipation, pleasure, and satisfaction – which pertain to healthy eating – the clients with ED experience craving, the feeling of the loss of control, and guilt.
A story told me by one friend of mine helped me to see a lot of similarity between the life stories of the patients in the ED Clinic:
A young girl grew up in a family where the casual menu included a lot of perogies, pancakes, pies, and so on. Looking at her childhood photos she could say that she was a chubby girl but was not heavy. One day (she was about 10 years old at that time) her grandmother came from far away to visit the girl’s family. She had never seen her granddaughter before. The girl was very excited to meet her unknown grandmother. When the grandmother met the girl the first thing she said – in a joking manner – was “Oh, she is fat!” Those words had a huge impact on the girl, she refused almost everything to eat and lost a lot of weight. This situation of restricted eating lasted several years until the point when the girl made a friend who taught her how to induce vomiting. So, the character of our story became a bulimic. This lasted until her twenties. At this age she became a student of one of the major universities. As she said, her studies were very interesting; she socialized with other young people who were into learning as much as she was. The issues related to her weight control did not make sense any more. From then her eating disorder was over.
When trying to transfer this ED story to the Gestalt schema I noticed some resemblance between stories of others. We have: 1) a piece of information (new and negative) had been incorporated forcibly into the set of the girl’s knowledge about herself; 2) due to the high positive meaning of the resource of the information (her grandmother) it was accepted without any checking or critique (consequently it became an introject); 3) the girl was not aware of her emotions related to the grandmother’s remark; she didn't talk about it to anybody else. This fragment of her experience had not been assimilated, which means – it became traumatic and rigid.
Observing other people with ED we can see the links of the same schema: a subjectively traumatic experience in childhood and rigid understanding of the body shape issues. The fact of the “broken boundary" (which is a trauma) explains why the boundary has a defect and does not work properly; this fact also determines the main mechanisms which interrupt the contact (there are confluence and introjecting).
Having said this, we can see the scenario which is so typical for people with ED: usually they don’t enjoy eating; they have an inclination to introject, for not only the information related to food or body shape; they don’t know what their preferences are when they have a choice; often they are unhappy in their relationships – either not having them or being in confluence.
Therefore we can see that ED in the Gestalt key may be understood as a disorder of the “self” boundary functioning. I would go further and state that the “self” boundary and the traumatic experience are the most appropriate objects for therapeutic attention. The broken connection between biological and psychological, biological and behavioural, individual-behavioural and social (which significantly present in the nature of ED) can be restored by the restoration of the “self” boundary and completing of the traumatic experience which initiated the disorder.
