Anorexia Symptoms and Signs: More Than Weight Loss

 Anorexia nervosa is characterized by abnormal weight loss: An anorexic in the late stages of anorexia nervosa ill exhibit symptoms of severe weight loss and starvation. Detecting anorexia nervosa in the early stages of the disorder, however, is more difficult. Initially, it may appear that the anorexic is just focused on losing weight, but not to excess. Symptoms of anorexia may be further masked as many anorexics are secretive about their eating habits and weight loss, and will often deny that they are losing weight.
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.

References

American Psychiatric Association. (1994). Diagnostic and

statistical manual of mental disorders (4th ed.).

Washington, DC: Author.

Bliss, E. L., & Branch, C. H. H. (1960). Anorexia nervosa:

Its history, psychology and biology. New York: Paul B.

Hoeber.

Blos, P. (1962). On adolescence: A psychoanalytic

interpretation. New York: Free press.

Blos, P. (1967). The second individuation process of

adolescence. The Psychoanalytic Study of the Child, 22,

162–186.

Boris, H. N. (1984). On the treatment of anorexia nervosa.

International Journal of Psychoanalysis, 65, 435–442.

Bruch, H. (1984). Four decades of eating disorders. In

D. M. Garner & P. E. Garfinkel (Eds.), Handbook

of psychotherapy for anorexia nervosa and bulimia

(pp. 7–18).

Bruch, H. (1985). Four decades of eating disorders.

In D. Garner & P. Garfinkel (Eds.), Handbook

of psychotherapy for anorexia nervosa and bulimia

(pp. 7–18). New York: The Guilford Press.

Bruch, H. (1970). Psychotherapy in primary anorexia

nervosa. Journal of Nervous and Mental Diseases, 150,

51–66.

Recource:http://www.edreferral.com