«It is more likely that group process tells us something that our entrails could tell - hunger for example - about something that is not known cognitively»
(Banet, Bion Interview)
«We are threatened with suffering from three directions: from our own body, […]; from the external world, […] and finally from our relations to other men. The suffering which comes from this last source is perhaps more painful to us than any other. We tend to regard it as a kind of gratuitous addition, although it cannot be any less fatefully inevitable than the suffering which comes from elsewhere».
(Freud, Civilization and Its Discontents, S.E. X)

Eating disorders represent, both from a clinical point of view and from that of research, an area that is difficult to define, challenging any attempt of classification and organisation; all that in spite of a very rich and unmistakable symptomatology, so as of an amount of data and observations became enormous in the last years.
People working in this field, whatever approach they follow, continuously get in touch with the uncanny experience of a disease - namely a disorder, a disorganisation - taking its place somewhere between a body - devastated by symptoms - and a mind in danger as well, presenting itself with predictable features on the behavioural level and an unbelievable polimorphia on the psychodynamic level, making reference - both in aetiology and in therapy - to trans-individual dimensions.
It is a trivial remark this kind of pathologies always includes a confrontation with medical-biological aspects, as well as a reference to "social" aspects: from the more superficial keys in terms of cultural models to the traditional approach of family therapy, to the flourishing of specialised associations and centres. And to the more recent researches on group analysis.
In Experiences in Groups (1961), Bion wrote about diseases that «manifest themselves in the individual but they have characteristics that make it clear that it is the group rather than the individual that is stricken» (p. 102). These group diseases find their matrix in the protomental system, they are in other words a function of the group and must be studied in the group.
Examining psychoanalytic literature about anorexia/bulimia we often find the reference to an identity impossible to reach or to specific difficulty in the area of dependence; in any case, a reference to concepts connected to the idea of a perturbation in the relationship between the individual and his/her membership to his/her primary group.
In the following notes I'll try to connect some of the bionian ideas about individual-group relationship to the specific manifestations of eating disorders, with regards to the fact that some of these remarks could be valid also for different pathologies.
The aim of this paper is not so much to propose alternative aetiological explanations, as to stress the possibility of bringing group elements back to the individual dynamic. Though the most direct implications seem be addressed to group therapy, the stimulation is rather referred to a quality of analytic listening, in other words to a mental setting that is able to catch group implications as a basic characteristic of mental functioning.
I'll go on for grades, by associations and suggestions, in order to find more and more deeply the trails of belonging to a group.

From external to internal family. The problem of dependence and of trans-generational traumata.

Let's take a classical description of dependence, the one made by Philippe Jeammet. Behavioural disorders (not only eating disorders) during adolescence are characterised by the fact of being conducts in which acting prevails on thinking, that attack resources and potentiality of the subject, that are often difficult to restrict into a defined nosographical picture, but that always make clear a low Self/object differentiation.
The hypothesis on aetiology describes parents that tends to catch the baby into their psychic economy, denying his/her specificness and needs, and to use it as a repository of projections.
In metapsychological terms, unsuccessful primal internalizations and later repression limit the capacity of using advanced mechanisms of defence and condemn the individual to dependence from anticathexed objects.
Similar observations are made, in a different language, by Gianna Polacco Williams about infancy and adolescence: because of a serious deprivation or trauma, it is impossible to internalise a dependent relationship, that is then rejected in all its forms with the consequent prevailing of internal destructive objects and structures.
This is an useful and suitable viewpoint, both theoretically and clinically. Let's try another one. A person suffering from an eating disorder presents him/herself as a member - and a spokesperson - of a primal group (composed by the family, but also by a larger community of teachers, friends, family doctors and so on) which is functioning as a dependent group. Phenomenologically there's a great correspondence between Bion's descriptions (1961) and the experience of dealing - in effigie or concretely - with a group searching for an expert or a miraculous cure, having no time to loose, that would rather an hospitalization or at least practical indications about what to do and that is anyway very rapid in substituting this expert with a more miraculous one.
Otherwise, in the case of the dual of dependent group, with a primal group that is completely exhausted to provide for its more insane member, since «it is as necessary to have someone who is dependent as it is to have someone on whom depend» (p. 122). Dependence is in fact the psychological cause of group disease, while its protomental matrix is linked to the repressed basic assumptions of fight-flight and of pairing.
Bion also wrote that «the impulse of the group is away from the hostile object; of the psychiatrist towards it» (1961, p. 81), but getting towards is meant without being caught in the basic assumption. The other side of a family group in baD is the specialised group of doctors with its protocols for an integrated intervention, that can make really difficult to get in touch with repressed emotions that are confined within the protomental system.
Thanks to the effort to look from these two vertexes at the same time, individual biography and the currency of the membership, more meaningful images can emerge. On the one hand there's a person whose needs couldn't be acknowledged by his/her caregivers, particularly for all that regards the primal cathexis of sexual body since it represents something capable to create generational conflicts. On the other hand there's a family-group, that is scared about those emotions connected to novelty, excitement and aggressivness and that refuses to work them out, denying and cutting them off; a group stuck - by a particular psychological constellation of its member or by the impact of historical events - into the attempt to keep itself a step before mourning and separation.
Even at a first sight this double vision allows to comprehend contradictory and coexistent aspects, those linked to hysterical and/or obsessive disorders, that are put in the shade by an addiction-like behaviour and by psychotic-like phenomena.
Rouchy (1999) remarks as group is the most suitable device to treat the incorporated aspects - that is to say what is inside the individual because of its membership to a family-group, without being metabolised - since in group they can more easily unfold and transform themselves.
As regards dual setting, Gaburri and Ambrosiano (2003) suggest looking at rêverie as a «function of the relationship that the individual maintains with the group […] emerging from the level of separateness and difference that this relationship admits» (p. 77).

The clinical example that follows is just about an individual treatment.

Daniela, 20 years old, was sent to me by the psychiatrist treating her for depression, when violent bulimic attacks appear. Daniela is skinny and has a manifest physical disability, that tends to ignore; only after a few sessions, she says, very shortly, that the handicap is due to a serious premature birth. Furthermore, she's so intellectually inhibited that at first sight she makes me think to a minor mental retardation.
She has nothing to tell about her binge eating: attacks come and leave her so exhaust and depressed that she can't do nothing but «go and work - go and sleep»; thus she doesn't eat and this explains why - even without purging conducts - there's no weight increase, even if this possibility always makes her anxious.
Oddly she has really a few to tell about herself, her passion for sports, her job in the family company or about family itself. Daniela lives within a large and unified step family group, composed by young, active, affectionate and cooperative people. They work, travel, cultivate hobbies all together, awarding with no conflicts tasks and responsibility as well as merits and profits.
Her cousin, who's studying Psychology, tried to make a comparison between their family and the one described by the Handbook of Family Therapy under the entry "eating disorders", but she didn’t find any correspondence! As a matter of facts, I myself get a picture of a really good group, sincerely concerned about the disease of one member of its.
Anyway Daniela is obscurely anxious about the hypothesis of giving evidence of a family dysfunction and she’s frightened by the idea that our work could drive in this direction.
Quiet and modest, she carries on the sessions as she was taking a medicine and all that she wants is a speedy recovery; ”Nothing to declare” , I think every time I see her.
The treatment of a patient with such a little capacity and habit to talk gives great technical troubles. However we decide to continue our work, following the simple but fundamental task of talking about everything going on in her mind, in order to understand what happens to her. More often than not, it necessitates me to play an active role in giving her a start in what has the appearance of idle chatters, reports on little everyday events in a disconnected and meaningless form.
At first it was quite impressive how she tended to speak about herself using “we” instead of “I”; this bent will be a very important clue to me, in order to define her problem as well as in order to catch the core of her request for therapy.
After a couple of years, a slight accident just before an extremely valued sports competition makes light on her paralysing terror of being envied, because envy is felt as the source of irreparable physical damages. What’s more, all the family seems to share her terror: all of them agree on playing down the fact and getting a rid of it as soon as possible, there’s a kind of taboo about that. Daniela is upset, since she would like to talk about her delusion and, for the first time, she doesn’t feel supported.
But during the last two years she successes in making a trustful relationship with me and in gaining a little narrative ability. So, two months later, when her best friend got pregnant and decided to marry, a story about her family’s foundation comes out from “nowhere”. Her parents got married in their late teens in a shotgun wedding, when their eldest son was born (Daniela’s older brother), supported by the approval and the real aid of their respective families.
The sequel of this story will take some months - and other fortuitous events – to come out: soon after the wedding, a series of losses bereaved Daniela’s mother of her parents, leaving her alone in taking care not only of her son, but also of her younger brothers, that were still little boys. Six years later, when economic and logistic situation seemed to be restored, the parents decided to have another child: Daniela was born at only six months pregnancy, with really serious physical problems. Also in this case, the family faced the situation courageously and resolutely: Daniela received all the necessary cures, that took a long time and some pain, but she never realised of her handicap until the secondary school. The affectionate closeness of her kin made up for her poor insertion in the age group. Once again, Daniela “doesn’t notice anything”; the incomprehensible symptoms of depression and the even more absurd binge eating would appear only when she left school.
With great difficulty an hypothesis looms in my mind about a family reacting to unbearable traumata as a whole, but without any elaboration: they get losses over, that is they leave losses behind and never go back to the past.
My hard work corresponds to that of Daniela, who knows all the parts of this story (even if she doesn’t know much about her grandparents and she’d never seen their photos), but never tried to put them together, also hindered by the disproportion between the excellent results gained anyway (on an affective, social and economic field) and the “few” – numerically – tragic events. It seems impossible to give the right “weight” to sorrow, while it’s quite simple to quantify successes (in terms of sports trophies, money, flats) as well as calories. On the other side it is just this quantity – “immoderate” in a certain sense – of good elements that causes the anguish of being destructively attacked, as well as excessive eating destroys Daniela’s life.
In this case getting “towards the hostile object” means putting together facts (illnesses, deaths) and fantasies, overcoming the heterotopy of elements and imagining a picture in which the “theft of sexuality” (the teenager conceiving a child) rises from envy e produces envy, such a destructive one to cause illness and death both in the old generation and in the new one.
Sexual and aggressive elements should be hidden, covered by a shared well-functioning that gives tangible evidence of a good behaviour and divine favour, where a fixed story (that of a united, cohesive and no-conflictual family) has tyrannically the leadership.
While I’m reconstructing this complex fantasy, Daniela finds one of those books such as “ten step to recover from bulimia” and she gets really impressed by the idea of “lack of self-esteem”. This light conceit takes the role of a selected fact, with a great effect: bulimic attacks gain a meaning, they become connected to everyday life events («I ate so much because I quarrelled with … because I didn’t success in doing …»).
Even without sharing directly with Daniela my hypothesis, I carefully approach the idea that painful experiences can leave their mark; Daniela transforms my interventions in something like: «If I always forget injuries, I can’t use my positive reaction to increase my self-confidence». At this stage she has often dreams in which she witnesses the destruction of valuable objects (houses, works of art, and so on) with a feeling of regret. At the same time she starts caring about her look, even apart form weight. Binge eating disappears, replaced by a polemic spirit that greatly disturbs relationships within family. Soon after a violent quarrel, her aunt acknowledges that she’s more mature by the experience of emotional troubles and psychotherapy. «Now you’re a woman», the aunt says, siding with her in a dispute with her parents.
Some months later, when it becomes clear that all the symptoms which drove her in therapy were overcome, Daniela will take the surprising decision to carry on with therapy “just for herself, to get a better understanding about herself”.
In the final stage, the pronoun “we” will be replaced by “X. and I” and her tales will become full of characters, all provided with noun, personal story, temperamental traits.

The anasemic and antimetaphorical core of anorexic/bulimic symptom is challenged because of the possibility of unfolding the incorporated family models by carrying “all of us” (with no distinction) within the consulting room, through an evocation that, at the beginning, was a little bit less concrete than if she really came with all her relatives. In any case, Daniela is, for her birth, concretely designated to represent the shared fantasy about the difficult handing down from generation to generation, within a “brothers community” castled in preserving a not controversial image of equal youth and equal responsibility (parents are always young and children are always “good boys”). Making clear her fear of being envied by the neighbourhood, as well as the care for her sex appeal or the participation to a couple that singles itself up from the rest of the group (i.e. Daniela and the aunt who “acknowledges” her) witness about a personal initiative of transformation, of exploring the familiar unknown.
This case is in some way “extreme”, since the family-group will come to really modify itself by the changing of its most fragile member.
Keeping a viewpoint on Daniela as a member of a troubled group helped me in finding a thread, a meaning in phenomena which otherwise would have showed a retardation or serious mental illness. In elements that clearly depends upon her group membership.

Narcissism/Socialism
«The individual is a group animal at war, not simply with the group, but with himself for being a group animal and with those aspects of his personality that constitute his “groupishness”» (Bion, 1961, p. 131). Bion will go on working with this idea postulating the existence of «two tendencies, one ego-centric, the other socio-centric, which may at any moment be seen to inform groups of impulsive drives in the personality. They are equal in amount and oppositive in sign. Thus, if the love impulses are narcissistic at any time, then the hate impulses are social-istic, i.e. directed towards the group, and vice versa, if the hate is directed against an individual as a part of a narcissistic tendency, then the group will be loved social-istically. That is, if A hates B, as an expression of his narcissism, then he will love society. “I hate B because he is so harmful to the society I love”» (Bion, 1992, p. 122).
Step one: since the beginning, the individual divides himself between the need for protecting his/her own identity, his/her thinking, his/her interests and the need for preserving his/her primal group, his/her pre-individual part, his/her adhesion to a group mentality. From this vertex, the destruction of logical connections (common sense) can be seen as a narcissistic reaction to preserve oneself from an excessive primal socialism.
With regards to eating disorders, this idea facilitates us in understanding the typical presence of serious thinking illness in some areas (food, weight, physical survival) in subjects who in other areas can show an advanced mental functioning and can use evolved defence mechanisms. Thus, paraphrasing Bion, “I hate my body, that is so harmful to the family I love” because it is a sexual body, that can provoke aversion and conflicts with the caregivers. This hate is so necessary to be maintained also by destroying
the touch with reality, with that common sense that clearly shows that the lack of feeding causes illness and death.
Let’s take a step further in this direction, examining two other quotations from Bion about
the range narcissism?socialism.
1. «Not necessarily self-love is narcissistic; not necessarily group-love is socialistic. At one pole there is an object; at the other pole an infinity of objects. At one pole there is an object towards which a group of emotions will be directed; at the other pole a certain number of emotions will be directed towards an infinity of objects, that owe the fact of becoming an infinite number to the splitting of one object» (1992, XXX)
2. «I shall suppose that the increase of intensity in narcissism is accompanied by a narrowing or concentration of emotion till it can be said to be one emotion […] Similarly the intensity of social-ism is accompanied by a widening of the spectrum of emotions. I shall further suppose that the total range from intense narcissism to intense social-ism is subject to splitting» (1965, p. 80)
We can think about eating disorders as a range from anorexia (nothing) to bulimia (everything), a range that is subject to splitting. Thus anorexia could be seen as the narcissistic extreme, where emotion concentrates itself till it is reduced to a point on an only object: the void, in its somatic-psychic symptom of hunger. At the social-istic extreme is placed bulimia, in which desire, aggressiveness and so on are dispersed towards a multitude of food-objects, again creating void. These extremes can be split off one from the other and from the rest of personality.
The range narcissism?socialism is important for its connections with meaning.
Just a few lines below the second quotation, that from Transformation, Bion explores the implication of the intolerance of no-thing, making clear that it precludes the representative function, in which even words become «a provocation to substitute the thing for the no-thing […] Thus actual breast is to be sought rather than the thought represented by this word» (p. 82). The problem is food or weight and these words don’t refer to anything but the actual danger they involve or the megalomania of staying in such a dangerous situation.
The “absurd binge eating” in Daniela stands for a dispersal of her sense of self in pursuit of an enormous quantity of things to ingest, followed by an as well absurd withdrawal in sleep ad mechanical activities. As a matter of facts, no-thing and thought are left out.
I shall close my paper with the dream made by another patient, at the end of a long and difficult individual treatment. Francesca has been suffering from bulimia for many years, after an early period of restricting anorexia, now she has no more symptoms, she got married and is going to conclude her therapy.
«There’s a family reunion in my living-room, when I see out of the window a huge ball of fire, a terrible red sun coming towards us. I have a feeling of an impending catastrophe, thinking that it will kill all of us. Then I notice that some among the presents are already dead and I suddenly calm down: it’s necessary».
Francesca interprets: the ball of fire stands for the end of the therapy, dreadful but necessary, and her relatives – even the dead ones – stand for all the things she cares of, at least together in the same place.
The possibility to work out separation and mourning is the outcome of reunification that is no longer felt persecutory (as the one represented by the ball of fire at the beginning), the result of the overcome splitting between narcissism and socialism. This opens the road to new experiences, particularly to starting a new family.

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