Body Image and Anorexia
The anorexic has an unrealistic view of the ideal body: Even in the final stages of starvation, an anorexic will still perceive herself as "fat," and take pleasure in losing weight.
The obsession with ideal body image and losing weight is not seen as abnormal by the anorexic: She may feel in control of herself when losing weight, and feel guilty when weight loss does not occur. The anorexic's distorted view of ideal body image overpowers all other concerns. Even when in treatment and understanding the life-threatening nature of starvation-induced weight loss, anorexics are still influenced by their desire for weight loss, often to the point of resisting treatment.
Anorexic Eating Habits and Weight Loss
The eating habits of anorexics vary considerably. While some anorexics severely restrict their eating to achieve weight loss, other anorexics go through cycles of binge eating followed by purging food through self-induced vomiting or use of laxatives. Regardless, the end result is excessive weight loss.
Anorexics feel hunger intensely while losing weight, but will not eat. Any suggestion of weight gain is met with high anxiety and fear. To mask their eating habits (or lack thereof) from other people, anorexics may employ a number of strategies, including socially isolating themselves.
Eating habits common to anorexics:
abnormal eating rituals (cuts food up small, moves food on plate but doesn't eat it)
cooks for others but does not eat herself
frequent weighing to monitor weight loss
denial of hunger
rigid eating schedule and severe calorie restrictions
avoids or skips meals regularly
exhibits an obvious reduction in eating
throws out food to avoid eating it
exhibits fear or anxiety before eating, and guilt after eating.
An anorexic's preoccupation with food may also include collecting recipes and storing or hoarding food. As weight loss becomes more pronounced, the anorexic may start to wear baggy clothes to hide the fact that she is still losing weight.
Mental Symptoms of Anorexia Nervosa
Certain mental symptoms are associated with anorexia nervosa. Anorexics often suffer from clinical depression, especially when weight loss is extreme and starvation results in low levels of the brain chemical serotonin. Anxiety is also a common symptom of anorexia, especially when the anorexic is confronted with eating.
Anorexics often have obsessive thoughts and/or obsessive compulsive disorders, regarding eating habits, weight loss, and other areas of their lives. Perfectionism or rigid thinking, while not symptoms of anorexia nervosa, are common personality traits of the anorexic and may contribute to her obsession with losing weight.
Denial of a weight loss problem and secrecy are common to anorexics. When asked, an anorexic is likely to deny being hungry, fatigued or thin. Due to the anorexic's abnormal ideal body image, she does not believe she is thin, so will sincerely believe she has not lost enough weight.
The drive to lose weight often leads anorexics to exercise excessively, and to continue exercising even if exhausted or injured. Despite starvation, malnourishment and low energy levels, anorexia nervosa patients are generally physically active. The goal is not for health but for continued weight loss.
Physical Symptoms of Anorexia Nervosa
The classic physical symptom of anorexia nervosa is weight loss leading to less than 85 percent of an individual's normal weight. Such excessive weight loss is both startling and noticeable. In addition to losing weight, anorexia nervosa symptoms may include:
amenorrhea (ceased menstruation)
bloating
breast atrophy
brittle, twisted hair
constipation
hair loss on scalp
lack of sexual interest
loss of body fat
low blood pressure
muscle atrophy
yellow, "blotchy" skin.
Amenorrhea
Amenorrhea, or the cessation of menstruation, is a common symptom of anorexia nervosa in women. Amenorrhea is defined as a cessation of menses for at least three menstrual cycles.
Even a few months of amenorrhea have been associated with a higher risk of osteoporosis (a severe loss of bone mass). Amenorrhea during the teen years is especially serious, as amenorrhea-caused osteoporosis can hinder normal bone development and stunt growth.
Severe Weight Loss and Starvation Symptoms
In the latter stages of anorexia nervosa the anorexic exhibits signs of starvation. Weight loss has become so extreme that the anorexic has practically no body fat. Bones are clearly visible through the skin, and muscles and breasts have atrophied. At this stage of anorexia, depression is common.
Once anorexia nervosa symptoms reach this level of severity, the prognosis for the eating disorder is grim. Intense and immediate medical intervention is required to save the anorexic's life.
Resources
American Psychiatric Association. III. Disease definition, epidemiology, and natural history. Practice Guideline for the Treatment of Patients With Eating Disorders, 2nd Edition. American Psychiatric Association, Washington, DC, 2000.
Beers, M.H. & Berkow, R. (ed). Eating disorders: Anorexia nervosa. The Merck Manual of Diagnosis and Therapy, 17th Edition. Merck Research Laboratories, NJ, 1999.
Behrman, R.E. & Kliegman, R.M. (ed). Nelson Essentials of Pediatrics, 3rd Edition. W.B. Saunders Company, Philadelphia, 1998.
Gowers, S. & Bryant-Waugh, R. (2004). Management of child and adolescent eating disorders: The current evidence base and future directions. Journal of Child Psychology and Psychiatry 45, 63-83.
Health Information Publications. (2003). What are the warning signs and symptoms?
National Library of Medicine. (updated 2004). Anorexia nervosa. MedlinePlus Medical Encyclopedia .
Rome, E.S. & Ammerman, S. (2003, December). Medical complications of eating disorders: An update. Journal of Adolescent Health 33(6), 418-426.
The main one: www.psychiatric-disorders.com
Identifying conflicts of anorexia nervosa as
manifested in the art therapy process
Dafna Rehavia-Hanauer, M.A.C.T. ATR1
Psychosomatic Department, Sheba Medical Center, Tel-Hashomer, Israel
While working as an art therapist treating anorectic
patients in an in-patient Eating Disorder Department
at a major medical center in Israel, I became
aware of a wide range of issues that arose within my
art therapy sessions. Although, the eating disorder of
anorexia nervosa has been explored extensively and a
variety of psychological explanations have been proposed,
the perspective taken by these theories did not
seem to address directly the art therapy process for
the patients with whom I was involved. As we know,
anorexia nervosa is a multifaceted disorder. Over the
years of my work as an art therapist, I realized that
there was a need to provide a fuller understanding
of the phenomenon of anorexia nervosa and the way
it manifests itself through art work and from an art
therapy perspective. I wanted to follow the central
themes that arose in art and the art therapy process
while working with anorectic patients. As proposed
by Schaverien (1994), art and art therapy may symbolically
replace food in the negotiation of the underlying
causes of anorexia nervosa. As I followed the
themes that emerged in the art therapy process I was
involved with, I found that my patients were trapped
in a pattern of conflicting themes. I therefore chose
to focus on these conflicts directly. In this paper, I
will concentrate on the conflicts that were identified
in the artistic process and art products of 10 anorectic
patients treated over a period of 6 months. The
definition of the conflicts and the ways they appear
in the art therapy sessions may be a useful tool for
assessment and treatment of patients with anorexia
nervosa. This study may also provide a more com-
prehensive description of the eating disorder anorexia
nervosa that is directly tied to the art therapy process
and as such may provide a new perspective on this
disorder.
Literature review
In extensive previous research, several different
factors have been defined that are important for understanding
the eating disorder anorexia nervosa.
These factors include socio-cultural, psychological,
family, biological, physiological, and developmental
factors. Yates (1989) stated that anorexia nervosa
would necessarily involve interactions between
socio-cultural, psychological, and biological forces
and that these forces must then be integrated within
a develop- mental framework. On a very basic level,
anorexia nervosa can be defined as a psychosomatic
illness that combines aspects of the physical body and
the mind (Yates, 1989). Research into the biological
and physiological factors involved in anorexia has
focused on both the outcomes and causes of anorexia.
Physical symptoms and signs usually reflect the
effect of caloric restriction and subsequent weight
loss (Pomeroy, 1997). Menstrual irregularities and
decreases in neuro-hormonal discharge are common
among anorectic patients (Yates, 1989). Because a
majority of patients diagnosed with anorexia are females
as were the participants in the present study, this
paper will refer specifically to females with anorexia.
Cognitive approaches to anorexia nervosa view
this illness in relation to a series of cognitive perception
distortions about body weight, shape, and eating.
The most documented of these distortions relates to
concepts of body image. In a significant study, Slade
and Russell (1973) found that patients with anorexia
nervosa overestimated their physical size.
Socio-cultural studies of anorexia nervosa focus
on the role of society in the development of this
mental illness. Bliss and Branch (1960) and Bruch
(1973) proposed that media and social messages
prevalent in western societies have propagated a vision
of beauty related to thinness that is a central
factor in the onset of anorexia.
Research that relates to family theory and dynamics
has proposed that the internal structure of
the family unit and especially the relationships between
the family members are a central cause in the
occurrence of anorexia nervosa. Eisler (1995) states
that anorexia may appear within an over close, over
involved family that has high expectations of its
children and which is unable to provide the impetus
and support for individuation and separation during
adolescence. In relation to the internal structure of
families, Minuchin, Rosman, and Baker (1978) proposed
that the anorectic patient reflects a structure of
internal conflicts that appears within the family.
Psychological research has proposed several
different explanations for the onset of anorexia.
An early psychoanalytical approach proposed that
anorexia is based on a symbolic desire to be impregnated.
This wish is unconscious and the denial
of eating is basically a denial of the desire for sexual
relations (Waller, Kaufman, & Deutsch, 1940).
The issue of sexuality raised by this approach has
been considered important by several researchers.
As reported by Dare and Crowther (1995), anorexia
has been related to cases of early sexual abuse and
trauma and to the onset of sexuality in puberty. This
approach sees the sudden entry into the world of
sexuality as a traumatic and fearful experience that
the anorectic patient has done everything to avoid.
A similar approach to anorexia nervosa sees the
Oedipus complex at the core of the illness. Anorexia
nervosa appears as a result of the child’s inability
to handle the Oedipus complex in early childhood
and on entry into puberty (Elizur, Tyano, Munitz, &
Neumann, 1991; Schaverien, 1995a, 1995b; Waller,
1993).
Developmental approaches to anorexia nervosa
pose that the processes of separation-individuation
and personality formation are central factors
in the onset of anorexia nervosa. Crisp (1980)
points out that anorectic patient have an intense
fear of entering adult femininity. This fear is related
to both the physical and emotional aspects
of growing up and becoming an adult. Bruch
(1973) poses a related but different developmental
issue. According to Bruch (1973), one of the main
characteristics of anorexia is an ingrained sense of
personal ineffectiveness. This personal sense of lack
of mastery and control results from a lack of individuation
between mother and child in early infancy
which is accentuated at the onset of adolescence because
of the social message of increasing autonomy
and independence. Ultimately, the child achieves a
sense of control and mastery by placing extreme
restrictions on the food intake of her body.
Selvini Palazzoli (1974) develops Bruch’s theory
by proposing an object-relations theory of anorexia.
In Selvini Palazzoli’s formulation the anorectic patient
identifies her body with the bad internalized
mother that has not been integrated in her psyche.
The body is identified as a maternal object. Once
physical changes start at puberty, the anorectic patient
understands these changes as a direct attack by
the internalized mother and an attempt to completely
devour her. The anorectic response is to fight back
against the internalized mother by strictly controlling
her body through excessive dieting and exercise.
Art therapy has specific qualities that make it very
suitable for treatment and discussion of anorexia
nervosa. It does not depend on verbal interaction
in order for therapy to take place and thus allows
the patient to express unconscious and unintegrated
internal materials without immediately activating
defense mechanisms against this content (Rubin,
1987; Schaverien, 1996). The non-verbal nature of
art therapy goes beyond the oppositional and defense
mechanisms. In many cases the anorexia nervosa patient
is resistant to therapy of any type. The presence
within the therapy sessions of an artistic process that
leads to a creation of an artistic product gives the
patient’s internal content a concrete form to relate to,
just as with the use of food. Schaverian proposes that
pictures may mediate between the inner and outer
world, just as food may be understood as negotiating
and mediating between the inner and outer world of
the patient (Schaverien, 1994). The artistic artifact
embodies all the conflicts, emotions and associations
found in the anorexia nervosa patient’s relationship
with food and eating behavior.
Luzzatto (1994) in her analysis of pictures produced
by anorexia nervosa patients pointed out that
these pictures reveal a conflictual situation, termed
by Luzzato a “Double trap.” This conflictual situation
consists of paradoxical communication—“I need
you—but you must not help me.” Linesch (1988)
suggested that anorexia nervosa represents an attempt
to solve a psychological conflict with a physical
resolution. This current study builds upon these conceptual
and therapeutic positions by analyzing how
anorexia nervosa is represented in the art therapy
process and artistic creation. In this research I closely
scrutinize the art therapy process with 10 anorectic
patients and thus may offer a unique opportunity for
describing this illness.
As will be described in the methods section below,
the central analysis conducted in the present study
related to the analysis of conflicts that emerge within
the art therapy process. Accordingly, one of the major
aspects of this study was the use of conflicts as
a central organizing concept. As described in the
literature, conflicts are an interaction between forces
that aim to reach opposing outcomes. Blos (1962)
has pointed out the important role of the conflict
as a positive aspect of the maturation process. The
main task of the adolescent is the development of the
ability to resolve intra- and interpersonal conflicts.
According to Blos (1962) this is the essential requirement
for developing into a mature individual. The
basic definition of a conflict (for both interpersonal
and intrapersonal relations) is an interaction between
incompatible desires, goals, and actions (Blos, 1962;
Cupach & Canary, 1997; Folger, Poole, & Stutman,
1997). In intrapersonal conflicts, these forces, desires,
goals, needs, and wishes are different aspects of the
self. For example, Freud’s structural concept of the
self proposes different internal agencies that vie for
power over the individual’s thoughts, feelings and
actions. These different agencies may be in conflict
with one another, each pulling in a different direction.
In a drive and defense model the superego defends the
ego against drives and urges of the id. Essentially, this
is a description of an intrapersonal conflict between
forces that wish to achieve very different outcomes.
Previous research has used the concept of conflict to
describe the illness anorexia nervosa. Stern (1991)
describes anorexia nervosa as the result of contradictory
interpersonal currents. Stern (1991) states:
They [anorectic patients] are frozen developmentally,
caught between opposing motivational
currents. Typically, the opposition is between legitimate
needs of the self (such as needs for emotional
nourishment, affect containment, emphatic mirroring,
or support for separation-individuation) and
some form of characterological self-denial, selfsacrifice,
or self-distortion that has its roots in early
(and often continuing) requirements imposed by the
family system—especially the mother–child dyad.
Thus at one level (usually unconscious) the eatingdisordered
patient is seeking a missed developmental
experience that is necessary for the growth of the
self, while at another (often more conscious) level
there is an apparent disavowal or repudiation of
these need, and of the kind of object (or self-object)
relationship necessary to meet them. (p. 87)
In this description of anorexia, Stern integrates developmental,
social, personality, and psychodynamic
approaches to anorexia within the context of opposing
forces within the individual patient. This approach
places early needs for emotional support and symbiotic
relations that are still active within the anorectic
patient in opposition to the patient’s current personal
and social requirements for autonomy and individuation.
These forces work to achieve very different
outcomes and thus constitute a conflictual structure.
Research into conflicts has shown that conflicts are
present throughout an individual’s development.
Dunn and Munn (1987) and Eisenberg (1992) have
documented interpersonal conflicts in early infancy
and childhood between parents and infants. These
conflicts are frequent and on going. As reported by
Lloyd (1987) intra- and interpersonal conflict is a
very common daily occurrence for adolescents.
The main advantage of using the concept of conflict
in the description of anorexia in this study is that
it allows the presentation of a complex picture of this
illness. In this study the analysis of the data, revealed
that anorectic patients expressed in various modes,
the presence of opposing forces at work within her.
The way these opposing forces functioned and were
present within anorectic patients’ self can be best
described through the idea of conflict. This methodological
use of the term conflict also has the advantage
of allowing the description of anorexia to cross theoretical
boundaries and propose options that integrate
various theoretical approaches. Using conflict as the
basic unit of description is a methodological decision
and this arranges and directs the theoretical and empirical
rich description of the data in the current study.
Research design
The overall perspective of this study is of an
informed-insider investigating her own reports collected
over a period of 4 years working as an art
therapist with hospitalized anorectic patients in a
psychosomatic ward in an Israeli medical institute.
Recent advances in qualitative research methods have
proposed that the world of human action can only be
understood by looking at the participant’s subjective
understanding of that world (Geertz, 1973; Maxwell,
1996; Packer, 1989; Ricoeur, 1991; Rosaldo, 1989).
This point of view of a participant art therapist,
informed-insider’s perspective allows a rich description
of the components that interact within the art
therapy session. Shaverien takes a similar position
when she proposes that the art therapist should start
research from the therapist’s current professional,
conceptual and physical position (Schaverien, 1995a,
1995b). This methodological approach which focuses
on the investigation of the conflicts, the artistic processes
and art products that emerged from art therapy
sessions with patients who have been diagnosed as
having anorexia nervosa, produces information that is
deeply embedded within the art therapy process that
I as an art therapist have been directly involved in.
The study is based on a close analysis of art therapy
session summaries and is not committed a priori
to any particular theory. The analysis investigated
4 years of weekly art therapy session reports collected
during treatment of 10 anorectic patients by
the participant art therapist. The patients that the reports
relate to were all diagnosed as having anorexia
nervosa using criteria from the Diagnostic and Statistical
Manual of Mental Disorders 4th Edition
(American Psychiatric Association, 1994), clinical
interviews, and hospital observations. The diagnosis
was conducted by the medical staff (dieticians,
nurses), the ward psychiatrists and the psychological
staff (psychotherapists and expressive therapists) of
the hospital.
The session reports were all written and collected
while these patients were in the hospital. The average
hospitalization period was 5.9 months. These
reports relate to anorectic patients within the age
range of 15–17.5 years of age. These reports were
not written originally with any intention of using
them for research but rather they represent the participant
researcher’s session summaries following each
art therapy meeting. These reports are extremely
detailed and include illustrations of the original art
works and products produced by the anorectic patients
during treatment. All art therapy sessions took
place in the same art room and related to weekly
sessions of 50 minutes.
The data analysis employed a cyclical, grounded
theory approach and was conducted in five stages
of analysis. Each stage of the analysis had its own
aim. During every stage of the study, each report was
read carefully and notes were taken throughout the
reading and analysis process so as to document the
researcher’s on-going thoughts and insights about
the data. The product of the first stage of analysis
was a series of notes on the identification of recurrent
themes that characterized the reports of several
patients. The second stage of analysis defined the nature
of the recurrent themes that had been proposed
in the first stage. This definition of themes involved
looking for the scope of the theme, the manifestation
of this theme in the art therapy process and the significance
of the theme for the patient’s treatment and
development. During reconsideration of the data set,
I realized that the proposed themes were not individual
entities but rather components of a structure that
involved binary opposition. These binary oppositions
were termed conflicts. In all, 32 potential conflicts
were defined.
The third stage of analysis evaluated the proposed
list of conflicts for their usefulness as a tool
for describing the content of the session summary
reports of the 10 anorectic patients. In addition, the
nature of the conflicts and their manifestation in the
art therapy process were reexamined. The conflicts
were re-categorized into a smaller set of more inclusive
categories. The list of 32 potential conflicts was
reduced to 8 conflicts. In the fourth stage of analysis,
the conflicts were defined in both operational and
theoretical terms. The analysis focused on identifying
the conflicts and defining the conflict indicators in
both the artistic process and product in the art therapy
meeting.
During the fifth stage, the proposed conflicts and
the reliability of the conflict indicators were evaluated.
Two additional independent readers were used
to evaluate the reliability of the conflict definitions
and indicators. The readers were two experienced and
certified art therapists from a recognized institution
of higher learning. Each therapist was given a packet
that included the definition of the conflicts, a list of
conflict indicators and 20% of the researcher’s session
summaries following each art therapy meeting.
The 20% of the researcher’s session summaries were
chosen randomly from the complete data set. Each
reader independently read and analyzed the session
summaries. The readers were required to define and
mark on the report the conflicts that they found in
the summaries that they read. These independent
analyses were compared to the researcher’s analysis
in the preparation of these materials and a measure
of inter-rater reliability was calculated. In addition
the readers were asked to provide expert opinion as
to the definition of each of the conflicts. The result
of this stage of analysis was a modification to the
list of conflicts. Two of the conflicts were found to
overlap with the other conflicts and therefore the list
of conflicts was reduced to six core conflicts. The
readers’ comments were used to fine-tune both the
definition of the conflicts and their list of indicators.
Results: the six conflicts of anorexia nervosa
Before we can address the definition of the conflicts,
the first issue that has to be related is the
inter-rater reliability of the conflicts and conflict indicators.
As described in the research design, two readers
(experienced art therapists) were given 20% of
the session summaries to independently analyze for
conflicts. Their analysis was compared to the researcher’s
original analysis of conflicts from stage four.
The levels of inter-rater agreement with the readers
were relatively high. The first reader’s range of
inter-rater agreement with the researcher was from
78.5 to 87.5% with an average score of 82%. The
second reader’s range of inter-rater agreement with
the researcher was from 74 to 94% with an average
score of 85%. These results suggest that the definition
of the conflicts and their indicators is reliable.
As found in the analysis, this conflict is especially
prevalent at the initial stages of treatment with
anorectic patients. The anorectic patient verbally and
physically expresses resistance to any participation
in the art therapy process. This resistance reflects
an internal emotional state that involves antagonism
towards the creative process and the art therapist
(or what she represents i.e., an authority) within the
therapy session. On a verbal level this resistance and
antagonism is communicated through expressions of
hostility, suspicion, contempt, and objection to artistic
materials, the art therapist and the creative process.
Some examples of these objections are: “What,
are we in kindergarten?” “What am I supposed to do
here?” “What are you going to find out about me?”
“I don’t want to draw and I don’t know how” (to
draw, paint . . . ). On a physical level, this resistance
can be expressed by physically moving away from
the therapist or by the patient turning her back to
the therapist. Some patients express their resistance
by physically communicating extreme exhaustion. In
this state, anorectic patients may yawn, place their
heads on the table, or even lay down in the corner. In
one case, a patient actually hid in the corner with her
back to the therapist and her head in the corner. At
the same time this resistance is being communicated,
they also communicate their desire and curiosity with
art materials and the creative process. These conflicting
communications may be simultaneous or appear
with a time lag within the same therapy session.
On a physical level, these patients are drawn to the
artistic materials. They handle artistic materials that
have been laid out before them. The anorectic patient
seems unconscious of this desire and may suddenly
find herself feeling the texture of paper or suddenly
scribbling on paper. At the same time the patient
may verbally express resistance to the art therapy
process and to working with artistic materials in general.
Verbally, they may begin to discuss their artistic
tastes, technical artistic knowledge and may request
very specific and sometimes unusual art materials.
To exemplify the presence of this conflict within
the art therapy process consider the vignette:
Lee in her first session looked at me with a cold,
hostile expression. After sitting down, she moved
her body so as to be as far away from me as possible
without getting up. She held her head at an
angle with her chin slightly raised, and the general
impression was of hostility mixed with contempt.
Her posture communicated her suspicion of the
whole situation. She chose a piece of paper from
the table in front of her and began to draw with a
pencil. She held the pencil at a distance from her
by slightly moving her body backwards. The pencil
was held only by the top end. The way she positioned
herself and held the pencil communicated
her contempt of the artistic process. She acted as if
she was following orders but without any desire to
actually participate. Her drawing slowly produced
an outline of a guitar in the center of the page. She
became more involved in her drawing and the way
she held her pencil changed. She moved her hand
down the pencil and held it in a manner that allowed
much greater control. She also began to use
colored pencils. While she worked on the drawing,
her expression changed and she seemed to be concentrating
on the drawing itself. When she finished
the drawing, she looked up from the picture. She
returned to the posture and expression that characterized
the beginning of the session. Her expression
was cold, hostile and suspicious. However, she was
curious to know what her picture tells me and what
can I say about the picture that she doesn’t know.
Emergent conflict indicators
The following indicators of the first conflict
emerged from the multiple repeated analyses of the
reports. It should be noted that these indicators did
not appear in isolation but rather came in collections
of different indicators. It is also important to point
out that this set of indicators is not to be taken as
a classification system that can be used in isolation
for diagnosis. These indicators need to be considered
together and in their context.
Behavioral indicators of resistance to art therapy:
(a) Avoidance behaviors.
(b) Active resistance behavior.
Verbal indicators of resistance to art therapy:
(a) Statements of hostility.
(b) Statements of contempt.
(c) Statements of suspicion.
(d) Statements of passive resistance.
(e) Statements of devaluation.
Behavioral indicators of attraction to art:
(a) Touching and sensing behaviors.
(b) Artistic activity behaviors.
Verbal indicators of attraction to art:
(a) Statements of previous artistic experience.
(b) Requests for artistic materials or knowledge.
(c) Statements of pride in art work.
Conflict two: Intensive creation of an artistic object
and the desire to destroy it
This conflict arises during the patient’s active
participation in the creation of an artistic object or
immediately following completion of the artistic object.
While creating the artistic object, the anorectic
patient expresses feelings of disgust in relation to the
artistic object, herself as a person, parts of her physical
body and previous artistic objects that she has
created. The patient may even express the desire to
destroy the artistic object. These feelings of disgust
come after the patient has actually done a significant
amount of work on the artistic object and has put in
effort to actually create the object. This effort may be
half an hour of intensive work but in some cases was
the result of several sessions of work. This period of
intensive work by the anorectic patient produces an
artistic object that is characterized by its emphasis
on accuracy, controlled production and attempts to
make the artistic object beautiful. These attempts to
beautify the object include things such as making
sure that the color used is equally spread and of same
hue, choosing the most suitable color to fit the object,
or the addition of various decorations to the object.
Following this period of intensive work on the artistic
object, the anorectic patient states her disgust with
the object and desire to destroy it. These statements
are combined with statements of personal devaluation
such as “I am absolutely without talent” or “I
am not good at anything.” In some cases, the patients
act out their desire to destroy their artistic works by
tearing up the paper they are working on and throwing
it in the trash, cutting their work with a knife,
complete erasure of the object that has been drawn,
or squashing a clay artifact they are working on and
returning it to its original form of a lump of clay.
To exemplify the second conflict consider the following
vignette:
Lea’s first 2 months of treatment were characterized
by a consistent desire to destroy all of her works.
An agreement was made between Lea and myself
that she was not allowed to destroy her works but
instead, I as her art therapist would keep them for
her. At her tenth meeting she began to create a small
vase out of clay. She kneaded the clay making it
soft and pliable, and then she made a solid rounded
cylindrical shape with her hands and then began
to dig into the bottom of the clay and extract small
pieces. The next session while continuing working
on the clay vase, she made comments relating to
her body. Specifically she stated that, she would not
want her body to change and become round. At the
beginning of the next session, she looked at the vase
and said “it has a round boring shape; I need to
add something to it. It is not enough to have a round
vase.” While making these statements she felt the
vase, slowly stroking the outlines of its shape. She
then stated that “the vase is empty and boring, its
needs to be fuller.” She continued by making a small
flower bud for decorating her vase. She worked
intensively on this decoration, making, modifying
and remaking this bud several times. In all, three
clay flower buds were made and destroyed. Finally,
she attached the final decoration to the outside of
the vase. This took the whole of the session. In the
next session, she stated that what was needed for
the vase was a leaf. She chose a small piece of clay
and began to form a leaf shape. Having completed
a leaf shape she then stated, “It is too long” and
quickly squashed it returning it once again to its
original clay form. Once again using the same piece
of clay she made another leaf, this time she stated,
‘’It is too wide.” Once again she squashed the piece
of clay and started over. She made another leaf
and stated “it is too narrow” and once again she
squashed the clay leaf. She then, once again using
the same piece of clay made yet another clay leaf.
This time she stated, “Its size is just not right for the
vase.” Finally she gave me the vase and told me to
keep it.
Emergent conflict indicators
The following indicators emerged in the process
of the analysis of the second conflict:
Behavioral indicators of intensive creation:
(a) Artistic accuracy behaviors.
(b) Artistic decoration behaviors.
(c) Emotional involvement behaviors.
Verbal indicators of intensive creation:
(a) Statements of positive involvement.
(b) Requests for artistic help.
Behavioral indicators of destruction:
(a) Erasure behaviors.
(b) Destructive behaviors.
(c) Destructive behaviors in art.
Verbal indicators of destruction:
(a) Statements of rejection of art.
(b) Statements of destruction.
Conflict three: The desire and need to be looked
after and held and the verbal inability to directly
express this desire and need
In the current analysis, this conflict was mainly
found to arise at the beginning of treatment. However,
this conflict can arise at any stage of the treatment of
an anorectic patient. The appearance of this conflict
is connected to the state of the patient’s illness. The
more severe the symptoms of anorexia are, the greater
the likelihood is that this conflict will appear. In this
conflict, the anorectic patient communicates her need
to be looked after and held. This request for help can
be expressed through the patient’s interaction with
the artistic object or through the physical condition
and behaviors of the patient. Anorectic patients with
severe symptoms are extremely thin. In this condition
they are very weak and are consistently tired. Any
physical or mental activity requires enormous effort
from the patient. In some cases, these patients cannot
rise from their beds. Although they are in a severe
physical condition that obviously involves receiving
help, they verbally make no direct requests for help
from the therapist in any form. Through their physical
condition and by avoiding any verbal request for
help, they communicate their wish not to be and not
to exist. Within the art therapy process, the request
for help is expressed through the thematic content
of the artistic object. For example, one patient drew
a very thin female figure lying diagonally (in an
impossible position) above a sharp sword pointed
at her back. The figure faces death and will not be
able to hold herself from falling on the sword. This
creates a situation in which only external intervention
could actually save the thin figure. A common
theme that reflects this indirect call for help is the
theme of drowning. A more direct representation of
this need and desire for help is the use of motherly
images. Drawings of babies in cribs or young birds
in a nest can be used to express the desire and need
for help. In some cases, the patient verbally relates
to the thematic content of the artistic object. The patients
desire to be held and receive help is expressed
in relation to the constructed figures. In the patient’s
formulation, it is the figure and not the patient who
desires to be held and needs help. For example,
one patient working on a sculpture of a girl stated,
“the girl’s legs have to be strengthened so that she
won’t fall.”
Although the physical condition and artistic representation
communicate the patient’s desire to be
held and the need for help, the anorectic patient does
not verbally express this need or desire directly. An
extreme form of this conflict is the artistic expression
of the desire for death. Death is portrayed as an
encompassing experience that will bring the patient
peace through physical holding. In some cases, the
imagery of death that is used in this conflict is reminiscent
of images of the womb. Artistic examples
of this include drawings of figures in graves, figures
completely covered by earth or figures laying among
soft clouds and bleeding.
To exemplify the third conflict consider the following
vignette:
At the twenty-second art therapy session I placed on
the table a piece of (18__ by 12__) paper which had
been folded into four sections in front of Micki. The
paper was divided into four equal sections. Micki
was in a very depressed state following a slight rise
in her body weight. I suggested that we conduct a
discussion in painting. The rules of the discussion
were that one person would start to work on a specific
panel and then the other person would respond
and vice versa. Micki expressed her willingness to
cooperate in this discussion. I started by drawing
a line at the top left section. The line was at the
bottom of the panel and it had a curved center. The
line invited participation through the filling in of the
curved center. She responded by painting a black
patch of color at the top of the panel. Micki started
on the next panel below the panel we had worked
on. Micki took a black oil pastel crayon and colored
a third of the panel completely black. This section
was horizontal and started from the line of the
page. I responded by making a curved, curly line in
pencil opposite the black section. She continued by
making a jagged black patch that covered the top of
the page. This patch obliterated the top section of
the curved line I had made. I responded by making
a gray patch at the bottom of the page. The gray
patch was made using an oil pastel crayon and
completely covered the bottom of the page. The gray
patch ended with a sharp slope to the end of the
page. Micki responded by making a black patch on
top of the gray. Slowly the black patch turned into
the form of a figure. The figure partially covered the
gray area. The effect of this painting was of a figure
lying on top and partially within the gray area.
She then proceeded to draw straight lines from the
jagged black area at the top of the page into the
laying black figure at the bottom of the page. These
lines were drawn with a pencil. The area between the
black figure and the jagged black area was covered
with these pencils lines. I responded by strengthening
the gray area and adding gray to the lines
drawn by Micki. The effect of these additions was
to soften the lines Micki had drawn. I asked if she
wanted to give a name to the panel. After hesitating,
Micki named the panel “a woman in a grave.”
Emergent conflict indicators
The following indicators emerged as descriptors
of the third conflict:
Behavioral indicators of the desire and need for
help and to be looked after:
(a) Physical expressions of weakness.
(b) Physical expressions of the need to be held.
(c) Artistic expressions of the need for help
and to be looked after.
Verbal indicators of the desire and need for help
and to be looked after:
(a) Indirect requests expressing need.
(b) Projected requests for help on art object.
Verbal indicators of the inability to express the desire
and need for help and to be looked after:
(a) Statements of denial of illness.
(b) Statements of self-devaluation.
This conflict arises after the initial stages of therapy
have addressed the patient’s resistance to treatment.
This conflict arises while a relationship of trust
is being built between the therapist and the anorectic
patient. The anorectic patient may be suspicious of
the therapist and may resist the physical closeness
and intimacy of the individual therapy session. The
anorectic patient distances herself emotionally and
physically from the therapist. For example, a patient
may express extreme anger and not be willing to
come to therapy or the patient may test the endurance
of the therapist in being with the patient. The conflict
is between the patient’s needs to be in a childlike relationship
with others and her desire to be autonomous.
The anorectic patient wants to be supported and
helped by those around her, just like a small child
with her parents. For example the anorectic patient
can assume an embryonic posture in the therapy session.
This type of relationship includes the need for
constant reassurance and proof of unconditional love
and acceptance. This relationship is symbiotic in
nature. The patient may be unconscious of this need
for a symbiotic relationship with others. At the same
time, the anorectic patient desires to be autonomous.
She desires to separate herself from her surroundings
and to create her own individual and independent
personality. She desires to make her own decisions
and take control of her life. Her physical development
enhances this conflict. Bodily changes, such as
the physical developments of puberty, cause changes
in the way her surroundings relate to her and how
she relates to herself. With the appearance of physical
indicators of womanhood, it becomes difficult to
maintain the symbiotic relationships that the anorectic
patient needs. In addition the anorectic patient
becomes fearful that she will lose the love and acceptance
of those around her. In this state the anorectic
patient is extremely sensitive to any comments made
by those around her. Every utterance is analyzed
by the anorectic patient and categorized as proof of
acceptance or rejection by the people around her.
To exemplify the fourth conflict consider the following
vignette:
Gal chose to paint a boat in her seventh art therapy
session. She chose a 9__ by 12__ piece of paper and
drew a boat with colored pencils. The boat was
small and situated on a calm blue sea. In a distance
from the boat she drew a small island. She began to
speak about the painting and said “My dream is to
be alone on the boat and to reach a distant island
and live in a small house on the island.” She kept
fantasizing of a life of her own. Then she continued
by presenting an opposing desire for a close loving
family relationship “I want the boat to take me
with the people I love, with my family for a holiday
in a terrible place2 . . . eh eh (self-correction) . . . a
calm place.” In her verbal expression, she mixed
the Hebrew terms Ga Rua (meaning terrible) and
Ra Gua (meaning calm). The terms of calm and
terrible were directed at the presence of her family
in close contact with her on the fantasized island.
Emergent conflict indicators
The following indicators emerged as descriptors
of conflict four:
Behavioral indicators of the need to be dependent
and in a relationship with others:
(a) Childlike behaviors.
Expressions of dependence in the art process:
(a) Images and symbols.
(b) Use of art materials.
Verbal indicators of the need to be dependent and
in a relationship with others:
(a) Expressions of the desire for a relationship.
(b) Expressions of fears of intimacy.
Behavioral indicators of the desire to be autonomous:
(a) Distancing behaviors.
(b) Aggressive behaviors.
Expressions of the desire for autonomy in art:
(a) Images and symbols.
(b) Composition.
(c) Destructive acting in the art work.
Verbal indicators of the desire to be autonomous:
(a) Expressions of aggression.
(b) Expressions of self-distancing.
Conflict five: The physical development of female
sexuality and identity and the rejection of these
physical developments and identity
This conflict may arise at any stage in the art
therapy treatment and is related to physical developments.
For the anorectic patient this conflict arises
with the appearance of the physical indicators of
female sexuality such as the initial growth of breasts,
the appearance of genital hair and the beginning of
the patient’s period. These physical changes include
2 Please note that the Hebrew terms used by Gal in this
sentence were Ga-rua that means terrible and Ra-gua that
means calm.
changes in height, weight, and the shape of the
body. The patient’s body undergoes a series of relatively
rapid physical changes that are associated with
adult female sexuality. While the body’s appearance
changes rapidly, the patients’ mental representation of
the body does not. The anorectic patient rejects these
changes imposed on her body and on top of that is
fearful of these physical changes and developments.
This may explain the patient’s extreme discomfort
with any type of physical contact or intimacy.
In art therapy, this rejection of the body may be
expressed through the verbal denigration of female
figures and the execution of direct changes to the figure.
These changes can be the removal of body parts,
the reduction of quantities of material from the female
sexual indicators and the redrawing of external
contours. The patient may be disgusted by the indicators
of female sexuality that have changed her body.
For instance a patient may state ‘’I am a pig,” “I
am fat,” or ‘’I am a cow.” Disgust with the patient’s
body can also be expressed through extreme cleaning
rituals such as washing and rubbing her hands till the
skin is red and sore. In art this can be expressed as
the avoidance of art materials which consist of thick
liquids or soft, flexible solids such as clay.
The anorectic patient’s physical changes are accompanied
by personal and social sexual urges, desires
and the verbal and non-verbal communication
of these desires. Just as with the physical changes, the
anorectic patient rejects and attempts to deny the presence
of these urges, desires and communications. The
anorectic patient experiences these physical changes
and internal developments as an assault on her body
image and self-identity. She has a self-identity as a
young girl without the explicit sexual overtones or responsibilities
of adult female identity. Her immediate
social surroundings, such as parents and peers, are
sensitive to her physical changes and respond to her
according to her physical appearance rather than her
internal development of self. This creates a situation
in which the anorectic patient has to contend with
internal, physical, and social communications which
she rejects and denies. She experiences these new situations
as inconsistent with her own identity. These
urges and desires cause a sense of fear and confusion
in the anorectic patient and therefore they are
denied and rejected. The anorectic patient expresses
aggression against her own body. For example the
anorectic patient may cut herself repeatedly or deny
her body’s basic requirements of food and rest. In
art therapy, this aggression is expressed by the use
of images expressing self-punishment such as tied
female figures, hung female figures, burnt female
figures and dead female figures.
To exemplify the fifth conflict consider the following
vignette:
Danni looked through a magazine searching for
ideas. She rejected any suggestions I made stating
that she wanted to decide by herself. She began to
draw on a 9__ by 12__ piece of white paper. She
marked the borders of the page by drawing a pencil
line around the whole page. She drew a picture
of a boy in the middle of the page close to
the bottom of the page. The boy is drawn from the
back so that his face cannot be seen. One of his
hands is raised. He is not wearing any top but is
wearing trousers. She then prepared acrylic colors
and painted the boy. Danni gave the boy a deep
sun-tanned tone to his skin. Then she said “ What
is he, sun-tanned or dirty?” She then drew a path
around the figure leading to the top of the page
and added a red apple to the boys raised hand.
She considered out loud how to paint his trousers
with acrylic. She said “Shall I make his trousers
dirty?” She painted his trousers leaf green. She
painted his hair black and she was very pleased
with her painting. She said that he reminded her of
the Biblical character Adam. In her next session she
began to draw a female figure at the other end of
the path at the top of the page. She called this character
“Eve.” Eve had a very female body including
the indicators of adult femininity. She painted
Eve with very pale colors, and dressed her with a
small green swimming suit that covered her breasts
and genitals. She did not draw Eve’s face. Danni
explained this by saying that she was too far away
to have a face. She then worked on the path by
putting small paint strokes of color very close together.
She fills in the whole path between the two
figures using a pointillist style. She then drew a
series of green trees in the surrounding space. Having
finished the picture, she began to create a dialogue
between the two figures. In her dialogue,
Eve expressed anger at Adam for not being in contact
with her. Eve/Danni stated “You never come,
you never come on time.” “I have been waiting for
hours.” “I did the shopping and you didn’t come.”
The dialogue was very animated and included loud
tones. At the end of the dialogue, Danni began to
cry bitterly and complained that her father was
disappointing.
Emergent conflict indicators
The following indicators emerged as descriptors
of conflict five:
Behavioral indicators of physical development of
female sexuality and identity:
(a) Sexually enhancing behaviors.
(b) Behaviors of sexual attraction.
(c) Artistic representations of sexuality.
(d) Artistic representations of female identity.
Verbal indicators of female sexuality and identity:
(a) Evaluations of attractiveness
(b) Statements of undertaken female roles.
Behavioral indicators of the rejection of female sexuality
and identity:
(a) Sexually blurring behaviors.
(b) Excessive cleaning behaviors.
(c) Aggression towards own body.
(d) Artistic expressions of aggression.
(e) Artistic expressions of ambivalence.
Verbal indicators of the rejection of female sexuality
and identity:
(a) Self-denigration of physical self.
(b) Rejections of physical contact.
(c) Aggression towards male figures.
(d) Rejection of female figures.
(e) Ambivalence towards art figures.
Conflict six: The need for complete control and the
feeling of lack of control
This conflict is present throughout the art therapy
treatment of the anorectic patient. The intensity of
this conflict varies during the period of treatment. It
is connected to the patient’s feelings of insecurity,
anxiety, and fears. The more heightened the sense of
the patients’ insecurity, the greater the likelihood of
this conflict arising. The most obvious manifestation
of this conflict is the anorectic patient’s control of
food intake. By reducing food intake and taking part
in extreme physical activity, the anorectic patient
tries to control her own bodily growth and weight.
The objective of this control is to reverse physical
processes and/or achieve physical thinness as an ideal
of beauty. The need for control can also be expressed
through the use and development of cognitive abilities.
Anorectic patients put enormous efforts into being
excellent students at school and in explaining the
phenomena that they experience. In many cases, these
cognitive explanations seem to be distant from the
emotional content that informs them. For example,
one anorectic patient explained her own lack of worth
by explaining that she was the cause of her mother’s
chronic illness. The patient had worked out the details
of her role in her mother’s illness by pointing out that
when she was three she had tired her mother out and
was a very “bad child.” The therapists’ questioning of
the possibility that a 3-year-old child had the power
to cause a chronic disease was not addressed by the
patient because she had the right explanation and the
therapist did not understand. As in this example, this
need for control and rigidity in thought processes
can lead to feelings of omnipotence. The anorectic
patient exaggerates her own powers in controlling the
people and situations within which she is involved.
This conflict arises when physical changes take
place and when society makes new demands on them.
These changes create a sense of losing control over
their lives and a devaluation of themselves. For example,
many anorectic patients refuse to participate
in a new project for fear that it won’t be perfect and
won’t meet the required standards. In the art process,
this sense of loss of control is expressed by the inability
to work with art materials that they cannot control
directly. The anorectic patient in this state will
prefer to work with pencils or markers and object
to the use of paints or any other more liquid color
types. These patients may produce images of flying
figures, fairies and spirits. What connects these images
is the patient’s claim that they are spiritual beings
beyond the body. These patients also prefer the use
of verbal interaction to artistic representation. They
express fears that they do not know what can be understood
from their artwork. They feel that they have
much greater control over the words they produce.
The anorectic patient’s response to this loss of control
is to regain control through food intake and physical
exercise.
To exemplify the sixth conflict consider the following
vignette:
Ruth started her second art therapy session by
choosing to work with colored pencils on the 18__
by 12__ page that she had already started a session
before. She stated that she was not good in art and
painting. She then drew a small boy. The boy’s
hand was connected to a line that already existed
on the page from the previous sessions doodles. She
stated that the line was another snake. She drew
the boy’s facial features and then erased them. The
small figure was left with very blurred features. She
then drew a group of three balloons at the top of the
page above the boy. The size of both the small boy
and the balloons was tiny in relation to the snake
on the page that was drawn in the previous session.
Ruth stated that the balloons had run away from the
boy. I asked how she felt about the balloons running
away. She answered “I feel that all control over my
body has been taken away” (being in the in-patient
ward). She then looked at her doodle pointing out
another part of her drawing and said “that reminds
me of a shoe.” “It reminds me of Aladdin’s magic
lamp with Aladdin’s genie emerging.
Emergent conflict indicators
The following indicators emerged as descriptors
of the sixth conflict:
Behavioral indicators of need for complete control:
(a) Behavioral control of food intake.
(b) Artistic expression of need for control.
Verbal indicators of need for complete control:
(a) Expressions of control of food intake.
(b) Requests for clear explanations.
(c) Requests for artistic control.
(d) Statements of extreme powers—omnipotence.
(e) Statements of precision.
Behavioral indicators of lack of control:
(a) Resistance to art therapy.
(b) Artistic expression of lack of control.
Verbal indicators of lack of control:
(a) Expressions of lack of control of food.
(b) Expressions of helplessness and impotence
concerning art therapy.
(c) Expressions of helplessness impotence and
guilt concerning family relationships.
(d) Projective expressions of need.
Discussion
In this paper, the disorder of anorexia nervosa
has been described by focusing on the underlying
conflicts that emerged through the analysis of the art
therapy session reports of 10 anorectic patients. In
Table 1
Summary of theoretical underpinnings of six emergent conflicts
Conflict title Theoretical orientation
Conflict one: verbal and/or
emotional-behavioral resistance to art
therapy and attraction to artistic materials
and the creative artistic process
Resistance as a central part of anorexia nervosa. Resistance is a basic
defense mechanism against internal drives and desires (Boris, 1984;
Fischer, 1989; Swift, 1991)
Conflict two: intensive creation of an artistic
object and the desire to destroy it
The role of the art object as a transactional object that embodies the
conflicts, emotions and associations found in the anorectic patient
that may be negotiable. Aggression towards herself is projected onto
the artwork and the artwork becomes the object of “scapegoat
transference” (Schaverien, 1994, 1987)
Conflict three: the desire and need to be looked
after and held and the verbal inability to
directly express this desire and need
The desire for a symbiotic and dependent relationship with others
reflecting early problems in the object-relation stage of development
(Bruch, 1973). The inability to express this desire is related to in
Luzzatto’s (1994) description of the double bind
Conflict four: the need to be dependent and in
a relationship with others and the desire to
be autonomous
This need involves issues with separation and individuation in early
infanthood and early adolescence (Blos, 1967; Mahler, Pine, &
Bergman, 1975; Masterson, 1997). Family structure that inhibits
separation and individuation can lead to anorexia (Eisler, 1995)
Conflict five: the physical development of
female sexuality and identity and the rejection
of these physical developments and identity
Rejection of female sexual identity and its physical manifestations is
tied to early Freudian explanations of psychosexual development. In
anorexia this can be tied to basic drive and defense mechanisms, the
onset of secondary Oedipial conflict in puberty (Elizur et al., 1991;
Schaverien, 1995a, 1995b; Waller, 1993) or the rejection of a
mother’s sexuality (Selvini Palazzoli, 1974)
Conflict six: the need for complete control and
the feeling of lack of control
The need for control and the feeling of a lack of control has been
discussed extensively by Bruch (1970, 1973, 1979, 1984). In
anorectic patients food intake and body weight are controlled to
counter a basic sense of powerlessness and ineffectiveness
this context, anorexia nervosa is a complex illness
in which there is an interaction among opposing
desires and forces on different intra- and interpersonal
levels. In the current study, six conflicts were
found to be present during the art therapy treatment
of 10 anorectic patients. Although the current study
was not constituted within any particular theoretical
explanation, each of the six conflicts that emerged
from the analysis of the data has a strong link to
specific theoretical orientations. The relationship
between the emergent conflicts and their theoretical
underpinnings is summarized in Table 1.
As can be seen in Table 1, across all six conflicts
a range of theoretical positions is addressed in
describing the disorder of anorexia nervosa. These
positions include Bruch’s (1970, 1973, 1979, 1985)
explanation of anorexia nervosa in relation to powerlessness
and control, Freudian explanations of
anorexia nervosa as rejection of female sexuality and
the relationship of anorexia nervosa to processes of
separation-individuation. Essentially conflicts three
to six relate to the major explanations of anorexia
nervosa. It is important to note that the empirical
data of the current analysis found evidence for all of
these theories. Accordingly, rather than negating one
position or another, the analysis of the current data
set supports a more eclectic approach to the description
of anorexia nervosa. A description of this kind
should be able to address the variation in the disorder
rather than trying to limit the description to a
restricted theoretical position. As seen in the current
data set all four of these positions were represented.
Conflicts one and two are a direct result of the
setting of the data within the art therapy process. It
has already been documented that resistance is a part
of the process of treating anorectic patients but what
is interesting in the current setting is the way artistic
materials interact with this resistance. The willingness
of the patient to approach art materials interacts with
the actual resistance to treatment. When treatment
is through art a conflict such as this can concretely
arise. Conflict two provides direct evidence of the
embodiment of unconscious material in art and the
art process. The desire to destroy the artistic product
after putting effort into producing it demonstrates this
shift of aggression to the art process.
As seen in the description, vignettes and indicators
of each conflict, the art therapy process and art
products are a particularly good tool for exposing
and treating internal conflicts. The art product and
art processing have no difficulty in embodying conflicting
and unconscious internal material. The art
process makes these internal conflicts concrete and
gives them a form that is present within the treatment
session. This concrete presence is then open for manipulation
and negotiation in the therapeutic process.
The art therapist uses the art process and art product
in order to bridge the distance between opposing
forces. For the anorectic patient, the art process and
the art product embodies those conflicting forces that
constitute the illness anorexia nervosa.
The process of communication in art therapy with
anorectic patients is conducted through the art process
and product and this allows the creation of a therapeutic
relationship that is not intrusive and which
honors the autonomy of the patient. It is the concrete
presence of the art process and product that embodies
these conflicting forces of the patient rather than
the verbal interaction. The anorectic patient has put
enormous effort in to suppressing and denying some
of these opposing forces. The art process brings these
conflicts into the therapeutic process. Once they are
in the therapeutic space the split between opposing
forces becomes apparent. Therapy takes place through
the therapist’s negotiation and direction of the relationship
of the anorectic patient to the art process and
product. The patient’s recognition that internal conflicts
exist and that the art therapist does not reject
the patient as a result of their presence is a central
aspect of treatment. This concretization of conflicts,
acknowledgement of the presence of internal conflicts
and the reduction in intensity of the forces that make
up the conflict, reduces the resonance of these conflicts
within the patient’s mind. Rather than invading
her every thought and action, these conflicts are seen
in more moderate proportions. In the short-term, this
keeps the anorectic patient alive and allows her to
address these conflicts and thus, in the long-term, to
partake in the maturation process.
Final comments
The aim of this paper was to provide a description
of the eating disorder anorexia nervosa that was
directly situated within the art therapy process. The
current paper followed a qualitative approach to research
and explored the disorder anorexia nervosa by
analyzing in a detailed, systematic and in a cyclical
manner art therapy sessions summary reports. The
results describe the disorder through a series of six
conflicts. These conflicts embody a wide range of
theoretical orientations and suggest that the description
of anorexia nervosa needs a wide based eclectic
approach. Future research is needed to transform
these conflicts into a diagnostic and therapeutic tool.
The current paper is an initial stage that offers art
therapist the building blocks of a theory of anorexia nervosa that is directly situated within the art therapy
process.
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