The Theme of Death in the French and German literature on Eating Disorders

Craig Jackson Stephen Touyz

Wolfgang Lennerts

(Accepted 31 January 1994)

It is not widely appreciated in the English-speaking world that a number of articles written in French and German do address the role played by death preoccupations and concerns in the development and maintenance of eating disorders, particularly an- orexia nervosa. In previous published articles these important ”hidden” threads have been highlighted in examining in some detail, the writings of the German authors Binswanger, Von Weizsacker, and Thoma. In this article, the writings of other German authors are also briefly reviewed as well as the French authors Bensoussan, Fouraste, Raimbault, and Thouzery-Loras. Implications and issues are posed for both the re- searchers and clinicians alike contributing to the literature in English on eating disor- ders, who do not necessarily embrace these themes in therapy and who may not reflect their significance to theory in the literature itself. 0 1995 by john Wiley & Sons, Inc.

Two recent texts in German, Stierlin and Weber’s UnZocking the Family Door, and Feie- reis’s text, Diugnostik und Therupie der Mugersucht und Bulimie, both published in 1989 (the latter not as yet translated into English), address death themes. The first text does so by means of clinical/anecdotal material from ”survivor” families and the second text through the medium of the drawings of anorectic patients.

Unlocking the Family Door applies knowledge of a systems approach in family therapy to assist in the understanding of the complex dynamics within families that produce an anorexic daughter. Certain important factors characterize anorexic families. They are often multigenerational, close-binding, and emotionally self-sufficient. In these families the outside world is kept at bay because “outside” is believed to be hostile and danger- ous.

Craig Jackson, M.A., Dipl. Ed. Psych., is Senior Child and Educational Psychologist wi th the Special Education Service in Wellington, New Zealand. Stephen Touyz, Ph.D., is Clinical Associate Professor in Psychiatry, University of Sydney, and Head, Department of Medical Psychology, Westrnead Hospital, New South Wales, Australia. Wolfgang Lennerts, Ph.D., is Clinical Psychologist with the Windach Psycho-Somatic Clinic, Am- mersee, Federal Republic of Germany. Address correspondence and reprint requests to first author at Special Education Service, P. 0. Box 27-382, Wellington, New Zealand.

lnternationallournal of Eating Disorders, Vol. 17, No, 3, 229-234 (1995) Q 1995 by John Wiley & Sons, Inc. CCC 0276-3478/95/030229-06

230 Jackson, Touyz, and Lennerts

More importantly is the way the family idiosyncratically reacts to issues of separation, loss, and death. The authors repeatedly stress the importance of traumatic death-related events in families with anorexic members, and that some families seem to carry a heavy psychological burden of violent deaths. Having stressed this important factor, the au- thors do not then appear to address the apparent relationship between the traumatic events and the onset of anorectic symptoms, nor that violent deaths could bring about delayed post-traumatic stress reactions in family members, particularly those symptoms that are manifest in the nonverbal language of the anorexic’s body.

The profile of many of the families described is essentially that of the survivor family who carries the heavy psychological burden of a preoccupation with death and height- ened concerns and anxieties surrounding death. This important dynamic is unfortu- nately overlooked and receives scant attention in this systemic approach to the treatment of anorexia nervosa.

A discussion of some of the case histories included by Stierling and Weber in fact demonstrates that a better understanding of the dynamics of families that produce anorexic members may be secured through the psychology of the survivor rather than via an understanding of systemic family process. More than one theoretical explanation is possible. Arguably the critical issue to address is the impact of death-related events on the inner workings of the family and how these families deal (or fail to deal) with this powerful aspect of existence. It should not be of surprise therefore that the onset of anorexia is, in many cases, associated with the death of a family member. This was true of ”Paula.” Both mother and daughter saw themselves as the sole survivors of their family and only to be reunited with their family in death. Her maternal grandmother died when she was born and her life started out associated with death. At 3 years of age her father died of stomach cancer, at which time mother and daughter moved in with the paternal grandparents. Paula first showed symptoms of anorexia nervosa soon after the paternal grandmother died. Highly emaciated, she presented as a grotesque sight, the constant threat of death (or play with death), binding mother and daughter closer together, neither being able to survive without the other. Both had reached figuratively and literally a dead end.

The authors make no comments suggesting how issues of death, mourning, or loss may have been addressed therapeutically or indeed seem unconscious of the fact that the very language they use to describe this case history is highly evocative of death. They are more aware, however, of how the anorectic daughter could fill the place left empty by the loss through death of people who might otherwise have acted as confi- dante, relative, or friend to the mother. This was a relatively common factor in the families they treated. If the anorexic daughter replaces a dead peison, is it any wonder that the daughter by her emaciated and cachectic appearance communicates in her body language, a message of death?

In the case of “Christa” the onset of eating disorder began when her maternal grand- mother fell seriously ill. She described herself as dead when living with her parents, and only felt alive again when separated from them. In other family scenarios, there was a close relationship between the death of a father and the first appearance of anorexic symptoms in the daughter. Under these circumstances it has been suggested elsewhere that anorexic symptoms signify a form of mourning or arrested grief work (McA11,1983). In 7 of 8 cases in one follow-up study, the anorexic nervosa was triggered by a traumatic loss or separation, usually through death or serious illness of a close relative,

In ’Tetra’s” case a co-therapist became aware that Petra’s behavior seemed to mimic and be highly reminiscent of “Gabile,” a sibling who died in early infancy. In this

Theme of Death 231

dynamic the anorexic daughter replaces the lost baby. The loss of a baby may of course serve to register a powerful death imprint on mother and older daughter alike. The authors do in this instance directly address the impact of death on the family therapeu- tically.

The families are asked to go through a grieving ritual. They are helped by the thera- pists to find the missing grave. The family works out a gravestone inscription for their dead daughter. Petra, however, is against this-she will feel as if she is being buried as well, not surprisingly for she is indeed the replacement for Gabile. Although the ther- apists' impression is that something new is happening in the family, that "something" evades them, and they conclude the interview without the usual closing commentary. What may have happened without the therapists themselves being aware of the actual process occurring, is that by assisting the family with its grief work, the family had, in a symbolic sense, finally buried its dead.

"Kerstin" was born the same year in which her mother's father died. In 1966 the mother's only brother died in a car accident at the age of 19. Kerstin, now aIso aged 19, had developed anorexia nervosa. The authors acknowledge that with younger anorectic girls, the trigger factor in many cases appears to be an acute threatened danger of separatip or the actual experience of separation. Nor is the dynamic of identification with the dead ignored. In the case of "Maria," the family is posed the question, "Could there be a dead member of the family that Maria is trying to declare her solidarity with by slowly killing herself in this way?" (Stierlin & Weber, 1989).

Where it is considered that family members have not as yet come to terms with past losses and that these losses act as a major obstruction to co-individuation, the authors do prescribe mourning processes or grief rituals. Stierlin and Weber (1989) further observe that anorexic families have an unusually high incidence of early separations and sudden disastrous losses that appeared to spread like shock waves over the following genera- tions without ever subsiding entirely. Thus, family members ''. . . stick together at all costs, to cling to one another and at the same time to rely on each other unquestioningly and hence maintain hope of survival in a dangerously unpredictable world' (Stierlin & Weber, 1989). Paradoxically, however, within the family its members live out their life in the constant shadow of the presence of death. Petra senses, for example, the danger of a death hush in her house, so that she is in a dreadful double bind-there is danger outside her house but there are also psychological dangers within her house that its many doors cannot lock out. There is no escape from the presence of death.

It cannot be said that Stierlin and Weber (1989) ignore the important part played by death and its symbolism because death, separation, and loss feature so strongly as events in the histories of these families nor do the authors bypass these realities or ignore their implications for therapy. Yet, an impression is formed that death issues and understandings have not received the prominence they appear to deserve and that the theoretical model of systemic family therapy applied to deepen our knowledge of what is happening within these families has been inadequate to the task. It is suggested that reinterpreting these families within the framework of a culture of survival may provide such deepened understandings and appropriate theoretical schemata that make sense of the impact of death-related events on the traumatized individual, particularly the trau- matized anorexic individual.

The second German author, Feiereis (1989), in his text Diagnosis and Therapy in Anorexia and Bulimia provides a dynamic interpretation of eating disorders, mainly by way of an analysis of patients' creative drawings and artwork. Although these artistic expressions deal with a variety of themes, approximately 1 drawing in 10 is the subject of various

232 Jackson, Touyz, and Lennerts

morbid depressive, suicidal, and death-related topics and themes. Death fantasies were evident during therapy sessions, particularly where patients had suffered recent trau- matic losses. Individually and collectively patients reported sensing the danger of death, longing for death, a preternatural feeling that life was about to cease, and they also reported numerous death dreams during therapy. The manner in which death themes are communicated through the medium of drawings may be illustrated through four specific examples.

In Drawing 48, the anorexic patient is held in the claws of a big bird in the middle of a cemetery. She is in front of an open tomb surrounded by more birds and corpses. She is compelled, in spite of herself, to look inside the tomb. Drawing 232 features heads covered with what the patient terms anxiety masks. Her mother is pictured standing in her coffin. The picture with caption 33 is intended to convey the patient’s feeling that she would prefer to be dead, having previously eaten. Finally, in a drawing simply entitled ”1985” a grinning skeleton lies on a small couch next to a baby. The head of a boy is depicted looking in the opposite direction.

THE FRENCH LITERATURE AS REPRESENTED BY FOUR ARTICLES

Raimbault (1971) directly addresses death themes in anorexia nervosa. During his psychiatric interviews with young girls suffering from anorexia, Raimbault detected a high incidence of references by his patients to death and death-related (morbid) topics. This directed the author to a study of “the force and richness of a fantasy of identification with a dead person . . . the anorexia appears as an expression of a relation of which the anorexic patient is a focus, and as a message from the anorexic patient to make under- stood her own desires, unrecognised by herself and her associates” (Raimbault, 1971).

Raimbault presents in his article the case study of ”Therese,” whose elder sister ”Odile,” died in an accident when she (Therese) was 6 years old. The body of an emaciated anorexic, he argues, is a caricature of what we can imagine will remain of the body after death. Therese, in a sense, carried the bodily image of her dead sister back into the realm of waking life and thus identifies with and becomes her dead sister. It is not insignificant to observe that Therese became anorexic at 15 years of age, the same age as her sister when she died. What the anorexic tries to do, postulated Raimbault, was not to die but to become the dead person.

The main theme discussed by Fouraste (1979) is that of delayed filicidal impulse. According to the author, anorexia represents a wish for death whereas the disinvest- ment and autodestruction of the body of the anorexic convey the image of death. The body becomes an object, nonaggressive, noncommunicative, evoking death. The an- orexic is the subject and the object of her own death, reflecting the death lived in her mother and father. ”Cathy” in the case study presented is the product of a cold and dead marriage, and the failure of the marriage has brought about Cathy’s death wish, which is contained in, and communicated by, her sick body. Although all forms of eating disorder may be grounded in a neurotic family function, the reasons for a specific symptom choice are not fully understood. The author concludes that in certain cases of eating disorders, “compliance to the parental unconscious wish towards obesity, skin- niness or anorexia is one of the major factors in the development of the specific symp- toms” (Fouraste, 1979).

Thouzery-Loras’s (1984) contribution comprises a detailed case history presentation that gives a phenomenological insight into the idiosyncratic perceptions of a young

Theme of Death 233

patient of 19 years of age with anorexia nervosa. She had suffered from the illness for the past 2 years and weighed only 32 kg. She avoided meat, a product of the suffering of animals, disliked the sight of dead fish, and avoided red vegetables as they reminded her of blood. Thus, Mademoiselle “0” seems to have formed a direct association be- tween eating and death, and seeks to control her food intake in order to negate her body and to achieve a transcendence over it. The weight of her body weighs on her existence like a tomb, which she tries to construct to overcome the emptiness of her existence. She took pleasure in trying to destroy her body and only regained life when she was in full control of it. The body that she is seeking to destroy affirms, in a sense, her own separate existence from her mother who had earlier tried to control and manipulate her body by giving it food. Previously “0” felt her body did not belong to her, and it was that of her mother, her mother’s toy. The mother is described as intrusive and manipulative, blam- ing herself for her daughter’s condition. She is a guilt-prone woman who does not feel emotionally involved in any relationship, and is mechanical in all her life with the exception of her fascination with death. Indeed, she presents as a necrophiliac mother who negates the existence and vitality of herself and her daughter.

Finally, Bensoussan (1986), discusses death imagery in the infantile development of eating disorders. The 6 young infants that the author describes are from three families with strange nutritional disorders. Their deaths appear to have been psychogenic. In each case there was a troubled relationship between the mother and the child. Infantile anorexia is conceptualized by the author as a symptom that unconsciously expresses the nondesire to live. Anorexia nervosa expresses itself in the language of death whereas treatment in a therapeutic environment should come to express itself in a language not of death but of life.

In the case histories there are details that suggest a lack of affect or of an emotional withdrawal of mother from children and of the death of the child in the mother’s mind before the child’s actual physical death. Grieving for “Mme I”’ was not too painful because the child had already ”. . . been dead a long time for us.” It would be interesting to know”, the author adds, “whether in fact she had ever been alive at all in her mother‘s mind” (Bensoussan, 1986).

DISCUSSION

The relationship between death and anorexia nervosa is at once obvious and yet deceptive (Jackson & Davidson, 1989). The obviousness is that the individuals suffering from this illness might be expected to and do frequently die (Theander, 1985; Rathasur- iya, Eisler, Szmukler, & Russell, 1991). The deceptiveness lies in the fact of a relative neglect of the study of death attitudes, cognitions, and orientations in both the etiology and treatment approaches of patients with dieting disorders (Warren et al., 1994).

Why is it that French patients suffering from anorexia nervosa appear to make fre- quent references to death and morbid topics during psychotherapy where as such pa- tients of other nationalities appear not to do so? It could be argued that this points to unique and distinctive cultural differences in attitudes to death. Are French and German clinicians less likely to down-play the significance of death-related themes in their pa- tients than therapists of other nationalities?

It remains a matter of some conjecture as to whether the dynamic pathogenesis of the disorder varies according to the national origin and language of the sufferer or whether

234 Jackson, Touyz, and Lennerts

the death anxieties, fears, and concerns are in fact part and parcel of the disorder irrespective of the nationality of the patient.

There seems to be little doubt that French and German clinicians appear to be more sensitive to both recognizing and dealing with references to death in their therapy than their English-speaking counterparts. A possible explanation for the greater empathy with themes of survival among European clinicians may relate to their status as survivor nations and their nationals as survivors of the dislocations following the first and second World Wars.

There may in fact be even more articles and references, as yet unlocated and untrans- lated into English, that also deal with death-related themes. Even so, most clinicians in the field, irrespective of their culture and linguistic background, often disregard or fail to react counter-critically to attempts to uncover the growing hidden literature on the theme of death in dieting disorders (Warren, Jackson, Thornton, Russell & Beumont, 1994).

It is hoped that this paper in some small way addresses this important but often neglected aspect of anorexia nervosa and encourages English-speaking clinicians to become more empathetically aware of the postulated importance and relevance of death themes in the treatment of their patients.

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