The body in adolescence

The Body in Adolescence The Body in Adolescence: Psychic Isolation and Physical Symptoms examines the affective experience of psychic isolation as an important and painful element of adolescent development Mary Brady begins by discussing how psychic isolation, combined with the intensity of adolescent processes, can leave adolescents unable to articulate their experience She then shows how the therapist can understand and help adolescents whose difficulty with articulation and symbolization can leave them vulnerable to breakdown into physical bodily symptoms This book introduces fresh ideas about adolescent development in the first ­chapter Subsequent chapters include clinical essays involving adolescent patients presenting with bodily expressions such as anorexia, bulimia, cutting, substance abuse, and suicide attempts Attention is also paid to adolescents’ use of social media in relation to these bodily symptoms—such as their use of online “pro-ana” or cutting sites Clinicians can feel challenged or even stymied when presented with their adolescent patient’s fresh cut or recent episode of binge drinking Brady uses Bion’s conceptualization of containment and the balance of psychotic versus integrative parts of the personality to examine the emergence of concrete bodily symptoms in adolescence Throughout, Mary Brady offers ways of understanding and empathically engaging with adolescents This book is essential reading for psychoanalysts and psychotherapists who treat adolescents and other patients with physical symptoms, as well as other readers with an interest in a psychoanalytic understanding of these issues Mary T Brady is a psychoanalyst and clinical psychologist She is in the private practice of psychoanalysis, psychotherapy, and consultation in San Francisco She is on the Faculty of the San Francisco Center for Psychoanalysis She is a member of the International Psychoanalytic Association and the American Psychoanalytic Association She has published widely on adolescence and bodily symptoms In 2010 she won the American Psychoanalytic Association Ralph Roughton Award for her paper, “‘Sometimes We are Prejudiced against Ourselves’: Internalized and External Homophobia in the Treatment of an Adolescent Boy.” Praise for The Body in Adolescence “This book by Mary Brady is a matter of absolute necessity in the literature of Psychoanalysis Presenting her own clinical experience with young people ‘of our times’ – in which the body is taken as the seat of conflict – we can see an experienced and dedicated analyst working sessions with adolescents who suffer from the most frequent presentations of their age: eating disorders, cutting and substance abuse With masterful tact, she shows us how clinical work with these developing individuals enlightens us as to the singularity of young people, the dynamics of family groups, as well as the characteristics of a culture which, inundating the senses, aids and abets psychic isolation.” —Virginia Ungar, M.D., Training and Supervising Analyst, Buenos Aires Psychoanalytic Association and President Elect of the International Psychoanalytic Association “This is a very fine book It enormously extends the range of our understanding of disturbed adolescents The author has great expertise and wisdom, and her beautiful clinical stories are also informed by serious scholarship Her identification of the sense of psychic isolation felt at times by even the most ordinary – and ordinarily sociable – adolescents as a major issue in adolescent psychopathology, is clearly a breakthrough She draws our attention to their attention to their bodies, and her descriptions of her tact and sensitivity with these very touchy wounded young people are a joy to read.” —Anne Alvarez is a Consultant Child and Adolescent Psychotherapist, and retired Co-Convener of the Autism Service, Child and Family Department, of the Tavistock Clinic, London “In this book Mary Brady puts her finger on two crucial areas of adolescent anxiety, each of which makes the other one worse She finds that loneliness is almost universal; adolescents’ frenetic socialising is often a defence against this The other is their preoccupations with their bodies whose rapid changes fill them with terror Their bodies are the seat of projections of disturbing feelings and unconscious beliefs Her clinical and literary illustrations bring this beautifully to life As Bion would have it she has identified the selected facts in the crisis of adolescence.” —Robin Anderson, Training and Supervising Analyst in Adult and Child Analysis at the Institute of Psychoanalysis, London; he was also Consultant Child Psychiatrist at the Tavistock Clinic where he was Head of the Adolescent Department The Body in Adolescence Psychic Isolation and Physical Symptoms Mary T Brady First published 2016 by Routledge Park Square, Milton Park, Abingdon, Oxon, OX14 4RN And by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an Informa business © 2016 Mary T Brady The right of Mary T Brady to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988 All rights reserved No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Brady, Mary, 1959The body in adolescence: psychic isolation and physical symptoms / Mary Brady pages cm 1.  Adolescence 2.  Adolescent psychology 3.  Social isolation I.  Title BF724.B693 2015 616.89'140835—dc23 2015020715 ISBN: 978-1-138-79775-8 (hbk) ISBN: 978-1-138-79776-5 (pbk) ISBN: 978-1-315-75690-5 (ebk) Typeset in Times New Roman and Gill Sans by codeMantra For Carey This page intentionally left blank Contents Foreword ix Acknowledgments xiii Permissions xv Introduction 1 “Unjoined persons”: Psychic isolation in adolescence and its relation to bodily symptoms Invisibility and insubstantiality in an anorexic adolescent: ­Phenomenology and dynamics 24 Cutting the silence: Initial, impulsive self-cutting in adolescence 39 Substance abuse in an adolescent boy: Waking the object 57 “High up on bar stools”: Manic defenses and an oblivious object in a late adolescent 74 Sexuality unreceived and adolescent suicide 92 Pro-anorexia websites through an adolescent development lens 105 Index115 This page intentionally left blank Foreword In writing this book, Mary Brady has made a wonderful contribution to the psychoanalytic literature of treating adolescents It is an honor for me to comment on some of the notable highlights of her book Her focus on bodily based symptoms is timely As she notes early on, adolescents now come into treatment much more frequently with problems that manifest in what they are doing to their bodies We often first meet them when they are starving themselves, cutting themselves, intoxicating themselves, recklessly driving their parents’ cars, or covering their skin with tattoos and piercings In these situations, parents can seem forlorn, lost, incapacitated, and disinterested in what lies behind these physically extreme statements about disturbing states of mind Brady’s understanding of how these parental attitudes affect and shape an adolescent’s feelings of containment—or lack thereof—is repeatedly brought to our attention in each case In this book, the combination of her keen intellect, deep empathy, and years of experience in treating adolescents helpfully guides the reader into understanding her patients’ anguish We also learn about the healing that can come when these adolescents have access to such a dedicated and compassionate psychoanalyst, who sees them, listens to them, and is willing to venture where a psyche finds itself lost and stranded She comes to her professional life with exceptional credentials Brady is both an adult and child psychoanalyst Her interest in psychology, and particularly psychoanalytic psychology, is long-standing She graduated from Holy Cross College in Worcester, Massachusetts with a major in psychology Brady later attended The Wright Institute in Berkeley, California to complete her doctorate Finally, she graduated from first the adult and then the child programs at the San Francisco Center for Psychoanalysis She has extensive clinical experience in the treatment of eating disorders, a challenging field that is not for the faint of heart She continues to teach and lecture in a variety of psychoanalytic settings, locally, nationally, and internationally To have her now write this significant book is a fitting accomplishment that documents what many of us already know: she is a sensitive, wise, and talented clinician 104  Sexuality unreceived and adolescent suicide Parker, I (2012, February 6) The story of a suicide: Two college roommates, a ­webcam, and a tragedy The New Yorker Retrieved from http://www.newyorker.com/ magazine/2012/02/06/the-story-of-a-suicide Remafedi, G (2002) Suicidality in a venue-based sample of young men who have sex with men Journal of Adolescent Health, 31(4): 305–310 Russell, S & Joyner, K (2001) Adolescent sexual orientation and suicide risk: evidence from a national study American Journal of Public Health, 91(8): 1276–1281 Ryan, C., Huebner, D., Diaz, R., and Sanchez, J (2009) Family rejection as a predictor of negative health outcomes in white and Latino LGB young adults Pediatrics, 123: 346–352 Ryan, C., Huebner, D., Diaz, R and Sanchez, J (2010) Family acceptance in adolescence and the health of LGBT young adults Journal of Child and Adolescent Psychiatric Nursing, 23(4): 205–213 Savin-Williams, R (1994) Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: Associations with school problems, running away, ­substance abuse, prostitution, and suicide Journal of Consulting and Clinical Psychology, 62(2): 261–269 Tyler Clementi Foundation Mission and Vision Statement (website) (2014) Retrieved from http://www.tylerclementi.org/about/mission-and-vision/ Tyminski, R (2014) The Psychology of Theft and Loss New York, NY: Routledge Waddell, M (1998) The Scapegoat In R Anderson and A Dartington (Eds.), Facing It Out: Clinical Perspectives on Adolescent Disturbance London, UK and New York, NY: Routledge Zernike, K (2012, August 24) After gay son’s suicide, mother finds blame in herself and in her church The New York Times, A14–15 Chapter Pro-anorexia websites through an adolescent development lens In this chapter I will examine the disturbing world of pro-anorexia online activity “Pro-ana” sites include chat rooms, images of anorexic bodies, and tips on losing weight and maintaining underweight bodies—so-called “thinspiration.” Pro-ana sites take an at least partially positive view of eating disorders (Wooldridge, 2014b) There are similar sites for bulimics (“pro-mia” sites), self-cutters, and for those intrigued with suicide The juxtaposition between contemporary cyber-­culture and the extremely private world of psychotherapy is an intriguing one This chapter joins a larger conversation on the interface between Internet technology and psychoanalysis (Hartman, 201; Lemma and Caparrotta, 2014; L ­ ingiardi, 2011; Seligman, 2011) Many therapists would feel concern about their patients’ participation in proana sites, as some posts on these sites support destructive ways of relating to oneself However, the pervasiveness and appeal of these sites calls out for us to understand the felt need for them Pro-ana sites seem peculiarly the territory of their users Viewing them as an adult and an analyst of eating disordered patients, I feel like an interloper and a voyeur My viewer’s state of mind seems worlds away from that of my young patients in this arena And yet, in a way, that seems the point How we meet our patients in trying to understand worlds that can seem foreign to us? Eating-­disordered patients often feel we are asking something of them they don’t understand Often eating-disordered patients look at me blankly when I refer to the notion of telling me about a feeling instead of resorting to a symptom ­Additionally, a sense of generational difference in relation to these sites is important, as I will discuss below How are we to understand these sites and our patients’ subjective experiences of them? How can we avoid a judgmental attitude while not adopting a mindless acceptance? I will suggest that viewing our adolescent patients’ use of these sites through adolescent developmental concepts such as psychic isolation, identity, defiance, and contagion is helpful to our understanding Adolescence and adolescent states of mind The anonymity of the Internet makes it virtually impossible to obtain accurate information about the demographics of pro-ana participants, but studies suggest “most users are adolescents” (Wooldridge, 2014a: 3) This is consistent with my 106  Pro-anorexia websites through an adolescent development lens experience Additionally Csipke and Horne (2007) found, in the four secondary schools they studied, that 12.6% of female and 5.9% of male students (n=711) had visited pro-ana forums, often several times daily In this study the rate of female usage was twice that of males, so it seems (not surprisingly, as anorexia is estimated to have about a ten to one female to male ratio and typically to begin in adolescence) the most prevalent users are adolescent girls I suggest that it is useful to view pro-ana sites through the lens of adolescent development I not mean to imply that it is only adolescents who use these sites or that adolescent phenomena are always involved, but adolescent states of mind frequently seem relevant It is from adolescent patients that I hear of involvement with these sites Some teens feel that they find an important way to communicate through posts on these sites Anorexia can be viewed from many perspectives As discussed in Chapters 1–2, eating disorders tend to emerge during adolescence Enormous bodily upheavals are experienced in puberty—the body often expresses what the mind cannot yet contain during adolescence A variety of psychological factors can be considered in relation to the development of eating disorders: as a disturbed effort to separate and individuate from mother, as the body expressing unbearable psychic pain through refusal or binging symptoms, and as representing problems with identity and the construction of a self (Brady, 2011) These issues intersect with adolescent developmental experiences Psychic isolation Individuals with eating disorders are extremely preoccupied with eating and their bodies and often feel isolated with their problems In his research on pro-ana sites, Wooldridge notes, “I have been repeatedly struck by the experience of alienation so prominent among [their] participants Here young men and women lament their estrangement from friends and family and their extreme loneliness” (2014b: 209) He quotes a pro-ana participant who related: “[W]hen I first found a similar ED (eating disorder) web site at age 16 I nearly wept with relief—I had suffered alone in silence for almost five years” (2014b; 209) The psychic isolation of adolescence that can eventuate in bodily symptoms is often exacerbated by the hiding endemic to those afflicted with eating disorders This extreme loneliness and isolation is a significant factor in the usage of pro-ana sites In addition to all the other reasons teens are drawn to the Internet, finding others with similar preoccupations is compelling The relative anonymity of the Internet does allow the possibility for this bodily preoccupation to be conveyed, albeit likely without meaningful containment For instance, participation in pro-anorexia sites can generate competition to be thinnest, as can group therapy for anorexics (­American Psychiatric Association, 2000; Nygaard, 1990), but at least in the latter context there is a group therapist to try to identify and elaborate the processes at hand I have also seen adolescents who start out intrigued by these sites and then become frightened by their posts or interactions, feeling drawn into deep waters Adolescents need and deserve some level of privacy, but they also need adults Pro-anorexia websites through an adolescent development lens  107 not to wander away from reasonable concern As adults and therapists we need to inhabit a territory of knowing that we are foreigners to certain adolescent formations, but to remain in enough contact to be involved with the real problems and concerns of our adolescent patients For this reason psychoanalysts of adolescents need to be aware of these powerful online developments The Huffington Post website describes “a secret world of teenage ‘thinspiration’” (Gregoire, 2012) Gregoire comments on the astonishing growth of Tumblr She states that in the prior year the site “generated roughly 15 billion page views and attracted 120 million unique visitors each month.” She suggests that “[w]hat draws teens to Tumblr in the first place—the ease of sharing and finding bloggers with common interests, a parent free environment (now that Facebook has become family friendly), and the diary-like feel of its blogs—also makes the site conducive to health and weight-loss blogs.” Gregoire asserts that “thinspiration” sites have been around nearly as long as the Internet itself She claims however, that the “depth and scope of Tumblr’s teen thinspo community seems unprecedented” with their “eerily elegant images, sophisticated design, pop-culture r­ eferences, private messaging, and street-style sensibility.” The posted responses to this article were numerous, I will cite one: As someone who used to use Tumblr and other similar websites to express myself during hard times, this “expression” quickly turned into a dangerous trend My eating disorder was essentially encouraged through “thinspo” pictures, videos, and interaction with other girls struggling with eating disorders While it made me feel less lonely during an extremely difficult time in my life, this secret online world of people with eating disorders, specifically teenage girls, perpetuated into a daily routine of encouraging the dangerous activities I was already partaking in I would say without a doubt, Tumblr and other similar websites made my eating disorder stronger and my real self weaker (Posted 5/3/12 by Goldie Treasure; Gregoire, 2012.) The responsibility of Internet purveyors in this area is hotly contested Many have banned “self-harm” content, including eating disorders and cutting sites, but there are many reports of sites being closed down and users working around the ban or migrating to other sites Identity Questions of ownership of the body are latent in “many clinical presentations during adolescence … is it felt to belong to the young person or the mother?” (Lemma, 2014: 82) We can see why the battle to evade censorship of these sites is fiercely waged The evasion of censorship is an echo of the individuation process of adolescence played out in a struggle for control of the body It is helpful to consider eating disorders in adolescence as an extreme end, but still an end of a spectrum of bodily expressions in adolescence (­Anderson, 2005) Many referrals for psychotherapy in adolescence involve bodily 108  Pro-anorexia websites through an adolescent development lens s­ ymptoms—­eating disorders, cutting, substance abuse, suicide attempts, etc Bodily preoccupation with piercing, tattoos, pimples, etc., are a commonplace in adolescence Eating disorders that persist into adulthood have a more established feel; they become far more “what I do.” Experiences on pro-ana sites vary amongst individuals When an adolescent is connected with adults, they [the kids] might visit pro-ana sites, but not become obsessed with them For example, an adolescent patient was able to tell me that her pro-ana involvement on Tumblr was getting frightening for her and she decided with me to stop going on the site Mondzrak (2012) theorizes a contemporary culture of narcissism and ­ponders its effects on adolescents Part of this culture of narcissism is the idealization of youth and the degradation of aging Parents may find it harder to truly parent if they need to deny the loss of their own youth and the succession of generations Consequently, generational differences and conflicts can be avoided Generational conflict is vital to adolescent identity building Adolescents can reach for extreme measures to define themselves and to ascertain the engagement of the adults around them We can see how eating disorders seem related to this Adolescents seem to be saying, “as long as I’m thin, it doesn’t matter to you if I feel empty emotionally and binge and purge or starve.” Online “thinspiration” images are an example of this The emptiness of cultural values obsessed with external appearances, particularly for girls, is reflected here in extreme and even grotesque form These images seem like both an appropriation of these cultural values and an accusation of their hollowness Some adolescents convey a sense that they feel it is impossible for themselves or anyone else to understand them One such teen chaotically began to tell me about her online communications, including on pro-ana sites While I felt some concern about her involvement on the sites, her effort to communicate her own experiences seemed more crucial Here, it would be harmful to take a critical stance towards pro-ana sites instead of beginning to understand the meanings of my patient’s online communications Such interactions with teens can be complicated Some teens can begin to feel that, by our listening to their eating disordered behavior or online activities, we are condoning or collaborating in it This could signal the emergence of a transference involving a parental object turning a blind eye On the other hand, if teens feel we quickly question their involvements they can experience us as formulaic and rule bound At times we may need to realize that while as therapists we ­experience ourselves as sensitive and concerned, teens can see us as remote, middle aged, and part of a medical establishment Collateral work with parents can contribute to thoughtful parental involvement with Internet use Problems range from highly intrusive parents who have no recognition of any adolescent right for autonomy or privacy, to parents who a­ bandon any attempt to intervene with teens’ self-destructive or potentially ­ harmful involvements on the Internet.1 Pro-anorexia websites through an adolescent development lens  109 Defiance Anorexia can be an expression of a desperate need to control one’s body or to defy control of one’s body imposed by others: “It’s my body, not yours.” In that sense, defiant refusal to eat sufficiently is an extreme end of adolescent individuation Joining with other adolescents in defiance of the adult medical and mental health establishment can be part of the adolescent separation process Adolescents commonly flaunt parental oppression and join together in solidarity against adults Adolescents also become private where once they shared freely They withdraw from adults as their bodies and their thinking changes This separation often takes the form of defiance Defiance has its purposes, including useful purposes, such as trying on identities through opposition or provoking a needed limit ­Defiance has its dangers, but it can retain contact with health and other adult concerns, if only in projected form The hallmark of adolescence is being able to experience turbulence while being able to rely on adults for safety in some way Defiance can, however, lead to repudiation of bodily health and pleasure The rejection of those who try to post messages about the dangers of anorexia by regular users of pro-ana sites could, in part, be seen as part of this adolescent defiance process: “You can’t control me or my site.” Parents need to be cognizant and protective in relation to their children’s Internet usage Parents and professionals are also quite justified in making efforts to create guidelines for Internet providers But, I am suggesting that sensitivity to the adolescent’s search for individuation (sometimes even through defiance) needs to be seen along with the potential for harm Contagion Another aspect of the adolescent process relevant to pro-ana groups is that of contagion Contagion goes beyond mere imitation In experiences of contagion, the “other person’s emotional state invades you, so to speak, to set up a r­ esponsive feeling within you” (Stern, 1990: 62) Group contagion is possible at any age, but is especially evident in adolescence Pressures toward conformity, and at the same time toward individuation are at a height during this developmental period (­Waddell, 1998) As adolescents separate from adults they can evolve intense ingroup loyalties, on or off the Internet.2 It is a commonplace of adolescent group mentality that group membership can justify a harmful activity, e.g., group members reassure themselves that anorexia is not dangerous because others in the group are severely restricting their food intake Part of the psychotherapeutic process is to become known in another’s mind Eating-disordered patients often feel burdensome to themselves and others Therapy can allow a beginning sense that their feelings can be known and understood Some teens are able to expand on this understanding and become more open with others about their eating disorders One anorexic girl I treated became active in SWEAR (Students for Women’s Equality and Rights) discussion groups at her 110  Pro-anorexia websites through an adolescent development lens high school This struck me as a healthy development, away from the secret and ruminative aspects of her eating disorder and toward the possibilities of thought, relating, and a constructive peer-group process Connecting with like-minded teens seems to be a major motivation for those who frequent pro-ana sites If we contrast the kind of posts on these sites with the experience of a SWEAR meeting, we might see what these sites lack One mother told me recently of having found her year-old girl having on-line sexual conversations The Internet is rife with such misrepresentations and use by those too young to assess what they are getting themselves into With millions of users of pro-ana sites we must acknowledge we know little of their use Potential space vs psychic retreat Wooldridge’s (2014b) paper is the first discussion of pro-ana online activity in the psychoanalytic literature His commentary is based on extensive research on pro-ana sites, so I will discuss his conceptualizations here Wooldridge (2014b) employs two psychoanalytic concepts, potential space and psychic retreat, as contrasting ways pro-anorexia sites can be used He suggests that pro-ana sites “may provide participants with a potential space that fosters further psychological development, allowing [them] to play with ideas about relationship, identity, and even recovery” (2014a: 2) It is interesting that Wooldridge raises Winnicott’s concept of “potential space” in regard to pro-ana usage, because eating disorders themselves can represent the absent development of, or collapse of, potential space “Potential space” is initially an intermediate area between baby and mother Potential space develops only in relation to a feeling of confidence on the part of the baby, “related to the dependability of the mother figure” (Winnicott, 1971: 100) Potential space is linked with play and creativity and later in life to cultural experience Winnicott warns that when too much is injected into the shared space from someone other than the baby, then this becomes “persecutory” and the “baby has no means of rejecting it” (102) Wooldridge (2014b) describes a patient he treated who used pro-anorexia sites extensively When this girl was young, her mother had intruded her obsession about cleanliness into her daughter’s space, obsessively cleaning her doll A shared emotional space did not easily develop between this daughter and mother, and instead the girl turned to food as a concrete alternative The mother was not able to consider that there could be emotional meanings to her need to control her little girl’s doll, making it difficult for her daughter to have a sense that emotional needs can be met and understood This situation exemplifies Williams’s (1997) contention that anorexic patients have often suffered being excessively projected into early in life, resulting in the development of a “‘no entry’ system of defenses.” In Winnicott’s terms, the child who is intruded on would not easily develop the trust or relaxation necessary to promote an open shared potential space My speculation is that pro-ana sites are appealing because they allow for a reduction in the sense of isolation endemic to eating disorders and allow a contact Pro-anorexia websites through an adolescent development lens  111 that is not too threatening for individuals who may not yet have had ­significant opportunity to inhabit or develop richer shared spaces There are likely multiple additional motivations that could be considered, such as curiosity, exhibitionism, evacuation, etc I am skeptical of Wooldridge’s suggestion that online p­ ro-ana interactions can sometimes reach the level implied by the term “potential space.” Given the high level of use, it is clear that pro-ana sites have a significant attraction to their users, and the way they are experienced likely varies Woodridge conversely suggests that participation in pro-ana forums may for some represent a “psychic retreat, in which cyberspace becomes an escape from a reality that has become unbearable.” Psychic retreat is a Kleinian concept, linked with pathological organizations, and has been particularly written about by Steiner Steiner considers a psychic retreat an equilibrium where there is a respite from anxiety and in which “reality is neither fully accepted nor completely disavowed” (1993: 88) The psychic retreat is defensive against the experience of loss, fragmentation, persecution, guilt, or despair None of us can unremittingly face reality, but “problems arise when the evasion of reality becomes long-term or permanent The retreat may become … a way of life, and the patient may come to inhabit a kind of dream or fantasy world which he finds preferable to the real world” (Steiner, 1993: 88) Interestingly, Steiner suggests that in dreams the retreat can be “represented not as a place but as a group of individuals bound together in an organization The protection is provided by becoming a member of this group, which comes to represent the safe haven” (103) It does seem that pro-ana forums can function in this manner Anxieties that overwhelm the mind and are acted out on the body, indicate a dire need for a containing object When a containing object is not available or it is too threatening to be known at a depth, the most that may be possible (at least for a time) is the evacuation of anxiety and the retreat from real problems Wooldridge has described the mere reporting of weights and calories on these sites without any seeming hope for making meaning Likewise, the shared group identity can be used to retreat from concern about why one is anorexic, or the potential for harm Conclusion The heavy usage of pro-anorexia websites suggests that participants feel that having this space to be heard may be better than feeling there is nowhere to be heard It also seems possible that beginning communication in the disembodied and anonymous space of chat rooms may allow contact for some who find more personal contact too threatening For some, the use of pro-ana forums may be temporary and intermingle with other contacts For others these limitations in communication may become more entrenched and contribute to self-destructiveness Viewing our adolescent patients’ use of these sites through developmental concepts such as psychic isolation, identity, defiance, and contagion is a useful starting point to envisage their experience 112  Pro-anorexia websites through an adolescent development lens Notes The National Association of Anorexia Nervosa and Associated Disorders (ANAD) includes a list of suggestions for parents regarding Internet use, including in relation to pro-ana sites Unconscious processes are active within groups (Bion, 1961) as well as individuals The antagonism of users of pro-ana sites to those who post comments pointing out the harmful propensities of these sites could be an example of a group projective identification That is, the group can project anxiety related to the causes or effects of anorexia into these critics and distance themselves from anxiety in this way “­Outpourings of anger or frustration toward “outsiders” (e.g., parents or doctors) were common; ­outsiders were regarded as unaware of the nature and benefits “pro-anas” associated with their behavior” (Tierney, 2006: 184) References American Psychiatric Association (2000) Practice guidelines for the treatment of eating disorders (rev.) American Journal of Psychiatry, 157 (suppl.): 1–39 Anderson, R (2005) Adolescence and the body ego: The reencountering of primitive mental functioning in adolescent development Unpublished paper presented at The S ­ ixteenth Annual Melanie Klein Memorial Lectureship, January 8, 2005, Los Angeles, CA Bion, W (1961) Experiences in Groups London, UK: Tavistock Publications Limited Brady, M.T (2011) Invisibility and insubstantiality in an anorexic adolescent: Phenomenology and dynamics Journal of Child Psychotherapy, 37: 3–15 Csipke, E and Horne, O (2007) Pro-eating disorder websites: Users’ opinions E ­ uropean Eating Disorders Review, 15(3): 196–206 Gregoire, C (2012, February 9) The hunger blogs: A secret world of teenage “thinspiration.” Huffington Post Retrieved from http://www.huffingtonpost.com/2012/02/08/ thinspiration-blogs_n_1264459.html Hartman, S (2011) Reality 2.0: When loss is lost Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 21(4): 468–482 Lemma, A and Caparrotta, L (2014) Psychoanalysis in the Technoculture Era New York, NY: Routledge Lingiardi, V (2011) Realities in dialogues: Commentary on paper by Stephen H ­ artman Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 21(4): 483–495 Mondzrak, V (2012) Reflections on psychoanalytic technique with adolescents today: Pseudo-pseudo maturity International Journal of Psycho-Analysis, 93(3): 405–422 Nygaard, J.A (1990) Anorexia nervosa: Treatment and triggering factors Acta ­Psychiatrica Scandinavica, 82 (Suppl 361): 44–49 Seligman, S (2011) Psychoanalytic ideals, new technologies, and the expropriations of the corporate self: Commentary on paper by Stephen Hartman Psychoanalytic ­Dialogues: The International Journal of Relational Perspectives, 21(4): 496–507 Steiner, J (1993) Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients London, UK: Routledge Tierney, S (2006) The dangers and draw of online communications: Pro-Anorexia websites and their implications for users, practitioners, and researchers Eating Disorders, 14: 181–190 Pro-anorexia websites through an adolescent development lens  113 Waddell, M (1998) The Scapegoat In R Anderson and A Dartington (Eds.), Facing It Out, New York, NY: Routledge, 127–142 Williams, G (1997) Reflections on some dynamics of eating disorders: “No Entry” defenses and foreign bodies International Journal of Psycho-Analysis, 78: 927–941 Winnicott, D (1971) Playing and Reality London, UK: Tavistock Wooldridge, T (2014a) The enigma of ana: A psychoanalytic exploration of proanorexia Internet forums Unpublished paper given at Northern California Society for ­Psychoanalytic Psychology Scientific Meeting Wooldridge, T (2014b) The enigma of ana: A psychoanalytic exploration of proanorexia Internet forums Journal of Infant, Child and Adolescent Psychotherapy, 13(3): 202–216 This page intentionally left blank Index abandonment feelings 26, 33–36, 65, 68–70 adolescence: antisocial tendencies 58; bodily confusions and emerging sexuality 94; states of mind 105–10; in transition 4–5 adolescence, early 11, 19, 74; psychic isolation 12; stressed with new sexual capacities 12 adolescence, late 3, 74–90; death throes 74–75; immaturity of 89; manic defenses 76, 88–89; physical symptoms and emergencies 76–78; separation processes of 74–78, 82, 86–90 adolescence succession processes adolescent development: stage theories 11–12; weathering 18–20 adolescent doldrums adolescent moratorium adoption, feelings related to 45 adult identity, birth throes of 74–75 alpha function 5, 9–10 Anderson, A 95 anorexia 24–37; as defense against bulimia 34; and defiance 109; mirroring inability to say “no,” 34; websites for 4, 105–11 antisocial tendencies in adolescence 58 Asperger’s Syndrome 48 autonomy 59, 84, 88, 90, 108; establishing in late adolescence 76, 77, 82 best friend development 19–20 beta elements converted to alpha function 5, 9–10 binge drinking 3, 74, 77, 79, 81, 84, 88 Bion, W 5–6, 9–10, 12, 53, 58, 99 birth throes of adult identity 3, 74–75 bisexual See LGB blacking out from binge drinking 79, 81, 84 bodily changes 1, 2; and psychic isolation 8–20; strangeness at 8–9 bodily estrangement See estrangement from objects body: claiming ownership of 98–99; expression of psychic pain 15–18; expressions and eating disorders 107–8; integrating changes in adolescence 94; as target for punishment/discipline 40 boundaries, setting breakdowns in psychological space 10–11, 16–17, 92 Broucek, F 26 bulimia 89; and anorexia 34 bulimics 3, 21, 74, 79–80; websites for 4, 5, 105 bullying linked to suicidal behavior 93 Clementi, Tyler 3–4, 5, 92, 96–101 collaborative care 70 communication: to analyst 42–43; through cutting 45–54; through self-destructiveness 59–60; through the analyst’s feelings 47 conflicts, handling 6, 18, 75 conform, pressure to 100, 109 contact barrier separating conscious from unconscious 20 contagion and eating disorders 109–10 container/contained theory 5–6, 10, 26, 58, 97 containment: from concave to firm 58–59; failure of 39; familial 94–95; lack of 53; maternal 5–6, 10, 26 crashing a parent’s car 2, 9, 77 culture: being destructive to others 99; impact of changes 116 Index cutting 1, 5, 17–18, 21; continued reliance for communication 46–54; cultural meanings of 39; as failures in containment 39; representing attack on object and identification with abused object 44; as response to emotional problems 40–44; ritualized 2, 30, 43; signifying inability to verbalize emotion 45–46; symbolism of 2–3, 39; websites for cyberspace, use of 99–101 death throes of late adolescence 3, 74–75, 88 defense of the normal 99 defiance and eating disorders 109 deliberate self-harm (DSH) 39; epidemiology of 40 dependence and autonomy 76, 82 depersonalization 25 depression: and drug addiction 57; relating to experience of “dead” mother 68–69; and reparative processes 71–72 differentiation between self and object 24–25, 27, 30 dreaming/dreams 13, 17–19, 33, 35–36, 46, 62, 80–88, 111 dream space drinking See binge drinking drug addiction See substance abuse eating disorders 1, 2, 53; and contagion 109–10; and defiance 109; and identity 107–8; making problems visible 26; positive view of 4, 105; potential space 110–1; and psychic isolation 11–13, 106–7; psychic retreat 111 efficacy, sense of loss in anorexic adolescent 26 emotions 108–10; chaotic 3, 6, 12, 16, 29, 77, 79, 94–95; containment 52–53, 59; expressed on body 5, 9, 17; expressed through cutting 40–54; hiding by anorexic 34, 36 estrangement from objects 8, 12, 13–15, 40 family: denying the truth 95–96, 99; rejection of adolescent’s sexuality 94–98; silence about emotional problems 45–46 Ferro, A fractured reality 95 freakishness 4, 8, 92 gang mentality 100 gay See LGB generational conflict 5; and eating disorders 108 grandiosity 25 Green, J 25, 53, 69 guilt 62, 75–77, 86, 88–89; manipulation with 80–81 homologous process in the analyst 39, 42–43, 53 homosexuality and reaction to 92–101 identification: as solution to separation 82; with therapist 19–20 identity: anxiety about 100; and eating disorders 107–8 If I Were You (Green) 25 imaginative elaborations immaturity of adolescent 11, 89 inability to say no in anorexia 34 inanimate exchanges 10 individuation 100; and eating disorders 107–8 insubstantiality in anorexic adolescent 24–37 internal containment 18 internal object relationship representing attack on object and identification with abused object 44–45 Internet: communicating through 49; and psychoanalysis 105 intervention in therapy 30 intimate space, lack of 2, invisibility in anorexic adolescent 2, 24–37 isolation See psychic isolation Klein, M 25 late adolescence See adolescence, late latency period 11 learning from experience 35 lesbian See LGB LGB adolescent suicide 92, 93–94 limits, setting 8, 61–62, 69 loneliness 1, 8, 20, 89, 92, 106 making a thought thinkable 3, 59, 69 male domination and lack of control by female 28, 32 maniac activity 30, 36, 84–85 manic defenses 3, 76, 88–89 Index 117 maternal connection with therapist 81 maternal containment 5–6, 10, 26 maternal object: deadened 68–69; inability to internalize 28–29; as oblivious 75–76, 81, 83–86, 89; perverse 87 maternal reverie 5, 9, 10, 26, 53 McCullers, Carson 1, 13 Member of the Wedding, The (McCullers) 1, 13–15, 19 menarche as a crisis 12 menstruation as a crisis 12 merging, phantasized 2, 24–27, 30–32, 36 mother: dependability of 110; lack of separation and differentiation from 24–25, 27, 30; lack of warmth 95 mourning murder of parental authority 4, 75, 77, 88 narcissism 5; impact of culture 108; objects 29 narcissistic object relations 24–25 narrative derivatives normalcy, psychosis of 99 object relations 8, 15; changes in internal and external 15; model 5; relating to dead object with substance abuse 57–60, 70; shifting oblivious object 3, 75–76, 81, 83–86; waking up 53–70, 77–78 omnipotent control 25 pain, physical and mental intertwining 42 parents: absence and feeling isolated 3, 33, 40–44; authority 29, 75, 77, 88; deadened 70; involvement with children’s Internet usage 108–9; mourning of as love objects 8; psychological murder of 4, 75, 77, 88; unwillingness to accept their children 3, 96, 98 Parker, Ian 96 passage of generations passivity 28, 32, 34 personality 2; balance between psychotic and nonpsychotic parts 95, 101; breakdowns 98; during latency 11; psychotic aspects of 10–11; re-organization of 10; stressed by new sexual capacities 12 phantasized merger with mother 2, 24–27, 30–32, 36 phobia 15 physical symptoms 3; in late adolescence 76–78 positions theory of development 11, 12 potential space 110–1 “pro-ana” websites 4, 105–11 pro-anorexia websites 4, 105–11 projective identification 5, 9, 12, 25, 34–35, 53 “pro-mia” websites 4, 5, 105 proto-symbolic 18, 39, 42 psychic isolation 1, 2; and adolescent suicide 92; and bodily symptoms 8–20; clinical example 15; due to lack of merging with another 26; in early adolescence 12; and eating disorders 106–7, 110–1; of homosexual teen 96; in The Member of the Wedding (McCullers) 13–15; physical expression in cutting 40–44; and suicidal behavior 3–4; vulnerability to body expressions of 15–18 psychological separation from parents 1, 8, 9, 77–78, 82 puberty: as a crisis 12; and onset of eating disorders 13 ranting 44–45 Ravi, Dharun 96 reparative processes and depression 71–72 rites of passage 4; and cutting 39 Rosenfeld, David 57, 65 Rosenfeld, Herbert 24, 26, 57, 75 scapegoat 100 school-based harassment linked to suicidal behavior 93 self: claiming oneself 97; sense of 8, 24–25, 27, 30, 32; and separateness between object 24–25; and unconscious relationships with objects 75–76 self-cutting See cutting self-destructiveness 21, 44–45, 90, 95 See also specific types; as communication 59–60; and emotional receptivity of another 42–43 sense of self 8; developing 32; separated and differentiated from object 24–25, 27, 30 separation: from one’s parents in late adolescence 74–78, 82, 86–90; between self and object 24–25, 27, 30 118 Index separation-individuation processes 3; in late adolescence 77–78 setting limits 3, 58 sexual abuse 28–29, 31 sexuality: emerging and bodily confusions 94; familial rejection of adolescents’, 94–98; of homosexual teen 92; negative image 29, 31; and stress dealing with them 12 sexual orientation as predictor of suicide attempts 93 shame as result of losing object 26 skin disruption of expressing disruptions in feelings 40–44, 54 Smith, Dawn 47 social exclusion 47–48 social media, role of somatic symptoms See symptoms; specific types stage theories 11–12 structure of sameness 19 substance abuse 1, 2, 3, 57–70; communicative projective identification 65; and identification with overpermissive paternal object 69; motivations for 71; reflecting unconscious relationship to ill or dead object 57–60, 70 substantiality and being seen by mother 24 suicidal behavior 5; predictors 93–94; and psychic isolation 3–4; websites for suicide 92; adolescent 92–102; attempts 1, 2, 3–4, 9, 39; demographics 93–94; psychoanalytic conceptualization of 94–96 symbol: definition 2–3, 39; joining together for sense of recognition 2–3, 39, 42 symptoms See also specific types: bearing them 9–10; of psychic isolation 15–18; stimulating the container 11; and unconscious object relations 57 theory of thinking therapist: identification with 19–20; maternal connection with 81 thinking: capacity to 34–35; theory of 9; unmetabolized states of thinspiration 4, 5, 105, 107 thoughts, unthinkable 3, 59, 69 transference 26–27, 29, 31, 36 transference-counter transferees 34, 55, 69–70, 75 transformation in hallucinosis 99 transitional space 19–20 truth, denial of in families 95–96, 99 “Truth Danger,” 95–96, 99 Tumblr 107 Tustin, Frances 54 unconscious object relations 75–76, 81 unjoined persons 12, 18, 20 unrest, developmental 13–15 violence due to sexual orientation linked to suicidal behavior 93 visibility related to being seen by mother 24 waking the ill or dead object 53–70, 77–78 weaning 30–32 websites: for bulimics 4, 5, 105; for cutting 4; for mental distress 4; pro-anorexia 105–11 Winnicott, D W 4, 58 withdrawal from childhood love objects ... what they are doing to their bodies We often first meet them when they are starving themselves, cutting themselves, intoxicating themselves, recklessly driving their parents’ cars, or covering their... processes in adolescence create pressures on the mind that can lead to astonishing new ways of thinking and relating Bion saw separation, or the experience of lack, as the prerequisite for thinking In. .. unpublished paper Ray Poggi has influenced my clinical thinking over many years and has kindly read several of these chapters During his training in psychoanalysis at the Topeka Institute for Psychoanalysis,