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Anorexia nervosa—The control paradox
Women's Studies Int. Quart., 1979, Vol. 2, pp. 93-101 Pergamon Press Ltd. Printed in Great Britain
ANOREXIA NERVOSA--THE CONTROL PARADOX MAR1LYN LAWRENCE
School of Applied Social Studies, University of Bradford, Bradford BD7 1DP, U.K. (Received and accepted January 1979)
Synopsis--Thispaper examines the Control Paradox which is at the centre of anorexia nervosa. The paradox consists in the very powerful control which anorexics exert in the area of food and weight and their own experience of themselves as utterly out of control. Anorexics are attempting to solve the problem of their own powerlessness and denigration as women by engaging in an internal struggle for self-control. The struggle takes the form of an effort to transcend the body which debases them, and to achieve self-respect through self-denial.
I n this paper I want to draw attention to the central paradox o f anorexia nervosa, and look at some o f its meanings and implications. I have called it The Control Paradox and stated briefly it involves the following contradictory statements. (1) Anorexics achieve perfect and absolute control at two levels: (a) control of size and shape, i.e. physical, and (b) control in the sense o f self denial, i.e. moral. In the course o f (a) and (b) they also have a controlling effect on other people a r o u n d them. However (2) anorexics experience themselves as entirely out o f control at two levels: (a) they are terrified of becoming fat--physical; and (b) they see themselves as gluttonous and d e b a s e d - - m o r a l . They give themselves over to doctors to be controlled, thus defining (1) as well as (2) as illness. T h r o u g h o u t the paper I will refer to the anorexic as 'she'. There are a few male anorexics. Hilde Bruch (1974) has a research sample of 1 0 ~ b u t it is overwhelmingly a problem which afflicts w o m e n and these are almost all women who have achieved highly in education. To begin, I should like to explain a little o f what is meant by control. The term control is obviously related to the term power, in the sense o f potency and force. In this sense it has the meaning o f power over something or someone. We do not normally use the term 'selfpower' in the sense of possessing the ability to force oneself. We would be much more likely to use the term 'self-control'. It is m y contention that m a n y of the issues underlying anorexia are crucially related to the use of these two terms. In order for an individual to be free to direct herself and take charge of her own actions, it is necessary for her to engage with other people in such a way that the interaction allows her this control. It m a y be necessary for her to exercise some power in relation to other people. W h e n anorexics talk about control, they invariably mean the power to regulate, c o m m a n d and govern their own lives and actions. They generally fail to do this by turning outwards and engaging with the world on their own behalf. Instead, they exercise self-control, which we might understand as power turned inwards. The battleground then becomes an internal one; the battle is fought within the individual rather than between the individual and the world. 93
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Paradoxically, this self-control does finally achieve what the woman herself has been unwilling to a t t e m p t - - i t has a controlling effect on her environment. An anorexic family member has a great deal of power in terms of the organization of the family around h e r symptom. Ultimately though, this power will be taken away. The 'symptom' is diagnosed, she is recognized to be ill and taken into hospital where she is controlled from outside herself. At the level of behaviour, the key feature of anorexia is an unshakeable desire to control both food intake and weight. The psychological need to control weight and to be thin are c o m m o n enough preoccupations amongst women in general. Clearly, this is related to the pressures upon women to conform physically to a culturally-defined stereotype which, at present, revolves strongly around thinness. It is also directly due to the tendency to assume that any difficulties in a woman's life can and should be solved by her changing herself in order to 'fit'. W o m e n are often encouraged to make physical changes in themselves in order for life to be better. New clothes, a new hair-style, a 'face-lift' are advocated not only by husbands but often by doctors too as a solution to women's depression. How many women have not at some time or other believed that life would really be better if only they could lose a stone in weight? Thus, controlling weight is used by many women as a substitute for controlling the real issues in their lives over which they have no control. This is well described by Susie Orbach (1978) in her chapter ' W h a t is thin about?' Hilde Bruch (1978) was the first writer on anorexia to point out that the need to control is a central feature of anorexia and that not far below the perfectly-controlled surface lie terrifying feelings of lack of control. Hilde Bruch calls it a 'paralysing sense of ineffectiveness'. These fears of total loss of control centre around the area of food. ' I ' m afraid to pass the cake shop in case the smell makes me lose control'; this fear was expressed by a w o m a n who had not deviated from her daily ration of 2 oz of cheese and a couple of lettuce leaves for 3 years. These fears also spread out into all other areas of life as well. One of my former clients, Sandra, who developed the problem soon after gaining a first-class degree in history, woke her mother early one morning demanding to be shown how to operate the automatic washing machine. She was tormented by the thought that if her mother were ever ill, she would not know how to work the thing and was terrified of being lefthelpless with it. Controlling her size and her food intake was for Sandra only one aspect of the need to control the environment as a whole. Sandra was unable at that time to face the real issues which were confronting her in her life. Her family had not only high academic expectations for her future, but also saw her as a person with the highest possible moral and human qualities. Sandra was, without conscious protest, being projected towards a life of social usefulness and self-sacrifice. This sense of a total inability to control the environment is compensated for by a desperate attempt to control the self in the environment. Anorexics appear to need to separate themselves from the environment. They need to define their own limits and set boundaries around themselves. The setting of boundaries around the self is a difficult problem for women as they are at least in part regarded as an aspect of the environment of others. W o m a n is the caret, the facilitator, receptive and waiting to allow herself to become 'something' in someone else's life. Being very thin seems to say to the world 'I have sharp contours, I am not soft, I do not merge with you. I have nothing to give you'. A recovered anorexic vividly described her anorexic experience to me in terms of 'needing to be closed up for a while, and very small. N o t receptive, not there for others'. I have mentioned that attempts at size and weight control are common features of
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women's attempts to adapt themselves to fit when life seems uncomfortable. Less common is the emphasis which anorexics put on rigid control of actual food intake. Control of eating becomes split off from control of weight and is in itself a separate activity. Weight control is the tangible proof that eating control is effective. I would like to stress the often disregarded moral dimension of anorexia. Too often, the aim of anorexia is thought to be slimming alone. It is regarded as a silly cosmetic obsession. The rigid control of food intake is, I think, more properly regarded as a kind of asceticism. In our culture, people are frequently taught to regard self-denial as a 'good' thing. However, it is a particularly 'good' thing for women, as it is women who are more inherently prone to badness and moral weakness. Eating is frequently put on a moral par with law-breaking or sexual transgression ('it's illegal, it's immoral or it makes you fat' !) Self-denial in the area of food will therefore bring with it some fairly far-reaching moral kudos, and will be an indicator of moral worth. In fact, anorexics engage in a number of other ascetic activities in addition to food limitation. Almost all subject themselves to violent over-exercise and tax their bodies to the very limits of physical endurance. Some also refuse to wrap themselves up in cold weather, feeling it is a sign of strength to force the body to withstand extremes of cold. Some anorexics (and chronic 'slimmers' too!) believe that the body burns up more calories if it is not protected from the cold and so not wearing warm clothes is also an attempt to lose more weight. It seems that losing weight and thus becoming attractive and acceptable must always be associated with some form of selfmortification. Gustav Mensching (1976) describes the purpose of the practices of asceticism as 'freeing the soul out of the prison of the body'. He talks about the dualism of body and soul which is a prerequisite for asceticism. The ascetic must fail to identify her true self with the body which she mortifies. In Weber's (1965) analysis of asceticism, the world-rejecting ascetic makes an identification between the world which is essentially sinful, and the body which attempts to keep the soul bound to the world. In order for the soul to overcome and transcend the base and wretched world, it must first subdue and overcome the body which is its prison. If we consider the history of women in religious life, we see that this dualism of body and soul is a fundamental necessity. Woman's body is regarded as essentially sinful, defiled and defiling. Moral perfection for woman can only be approached by the total denial and denigration of her body. In Helen Waddell's (1936) translation of the stories of the Desert Fathers, a number of Desert Mothers are also mentioned, terrifying achoresses whose selfmortification is blood-curdling. The point of particular interest is that most of the anchoresses mentioned are reformed prostitutes, while the anchorites appear to have been saints from birth. Even St. Mary, niece of Abraham the Hermit, who spent her first 20 years in utter purity has to go off and live as a'whore for 2 years before she can fully commit herself to the subduing and mortifying of her body. Women must, if they are to achieve spirituality and moral justification, experience and acknowledge the total sinfulness and moral disgrace of their own bodies. The ascetic rigours of the anchoress were thus carried out in the midst of overwhelming and terrifying guilt about their very nature and being. St. Pelagia, again a harlot, lived for many years as a desert hermit masquarading as a man. It was only after her death when the monks came to anoint the hermit's body, that her feminity was revealed. The monks were astonished that a woman could have achieved such sanctity. Maybe Pelagia knew that a woman could not have done. At any rate, her quest for moral perfection led her to the abandonment of her femininity. The most dreadful story of all the anchoresses is that of Thais, the story on which the
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novel Thais by Anatole France (1890) was based. Thais, the most sought-after courtesan in Alexandria is converted by the holy man Paphnutius. In order to establish her true penitence, he seals her up in a filthy, doorless cell to contemplate the despicable state of her soul. Three years later, he returns and drags her from her foul prison, although she begs to be allowed to stay. Within 2 weeks she is dead. What better illustration of man's need to punish woman for being what he demands that she be. One can hardly do better on this point than to follow Jean Baker-Miller's (1978) excellent arguments that woman's territory is essentially that of man's unresolved problems. Issues with which the dominant culture has never come to terms e.g. sexuality, death, emotion, are handed over to be the domain of woman. Thus man is enabled to exorcise a demon of his own by punishing woman for her sexuality. Asceticism for women then is an attempt to attain spirituality or goodness or moral strength or power by punishing and subduing that part of them which is both weak and sinful, their bodies. Here is a short extract from Ellen West, the case of an anorexic woman written up by Binswanger (1944): 'In the diary she continues to air her hatred of the luxury of good living which surrounds her. She bemoans her cowardice and weakness in not being able "to rise above the conditions", in letting herself at so early an age be made flabby by the ugliness and the stuffy air of the every day.' Ellen only feels morally justified when she is abusing her body most appallingly. 'She arrives completely emaciated, with trembling limbs and drags herself through the summer, a physical torment, but feels spiritually satisfied because she is thin. She has the feeling that she has found the key to her well-being.' In my experience few anorexics will account for their actions directly in spiritual or religious terms, though I have found a surprisingly high rate of religious affiliation and outlook amongst my anorexic clients. Most, however, express feelings about themselves very much like those of Ellen West. There is a general feeling that the world is a bad place. Most of my clients had what might be called a strong 'social conscience', and a well worked out view of what their role in social reconstruction should be. Coupled with this is the feeling that self too is very bad, every bit as bad as the world it would like to change. Clearly this relates directly to the position in which society places women, and to the taboos and denigrating explanations with which it surrounds them. The self-disgust which a woman learns for her normal bodily processes, such as pregnancy and menstruation; the 'choice' of labels to describe her sexuality (e.g. 'whore' or 'virgin'--'tight' or 'loose'); it is not difficult to understand why women associate their bodies with difilement and badness. Anorexia can then be seen as a logical strategy for denying this defilement and rising above it. The methods used are almost precisely those used by the Desert Mothers to achieve the same ends. The self-controlling aspects of anorexia, are, I think, less puzzling if we begin to see them in the light of other aspects of human experience which we are able to understand. I have talked about weight control for cosmetic reasons and weight control for ascetic reasons as though these were unrelated. In fact I should now like to suggest that they have quite a complex relationship. The idea of woman only achieving moral justification through intense physical self-control is so deeply entrenched in our consciousness that an important aspect of attractiveness or desirability in a woman is centred on her ability to deny herself. This is obviously true in the area of chastity. The woman must be warm and passionate with her chosen map., but is admired by him only if she has succeeded in denying
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and subduing her sexual feelings up to that point. This is obviously related to the ownership of women, but it is also found in, for example, the eroticism of the cult of the Virgin Mary. Her erotic attraction lies precisely in her virginity and more especially in the fact of her having borne a child without any of the 'pleasures' usually associated with its conception. There is no doubt that self-denial in the area of eating is also a source of attractiveness and desirability. Eating, especially in large quantities is an unseemly activity for women. The attractiveness of self-denial and spirituality in women is beautifully illustrated in Aldous Huxley's Crome Yellow with the story of the three Miss Lapiths. When George Wimbush goes for dinner with the Lapith family, he is struck both by the beauty of the three daughters and by the fact that they do not eat. He comments on their lack of a p p e t i t e . . . 'Pray, don't talk to me of eating', said Emmeline, drooping like a sensitive plant, 'we find it so coarse, so unspiritual, my sisters and I. One can't think of one's soul while one is eating ! ' . . . 'For his part, he thought them wonderful, wonderful, especially G e o r g i a n a . . . Georgiana was the most ethereal of all; of the three she ate the least, swooned most often, talked most of death and was the palest . . . . At any moment it seemed she might lose her precarious hold on this material world and become all spirit.' Mr. Wimbush continues to adore his ethereal and unattainable Georgiana until one day by accident he comes upon a secret stairway which leads to a room where he finds the Miss Lapiths--eating! He blunders out in horror and Georgiana is so ashamed that she agrees to marry him to ensure his silence. Many anorexics, while being able either to eat small quantities or even to overeat on their own, are quite unable to eat in front of other people. Most 'normal' women also overeat. But this is almost always done secretly and possibly confessed to other women. It is never an area of their lives which women share with men. It seems to be important for women not to be seen to need food in the way in which men need it. Indeed it seems that under-eating is an integral part of the 'feminine' image. Part of attracting men is pretending not to be human. This is reminiscent of the ascetic's aspirations to transcend her human nature by her austerities. The theme of control then, works at a number of levels of anorexia. Control of size and shape is seen as a means of taking charge of a world which is uncontrollable. The real issues which confront all women around control of their lives and ownership of themselves are lost beneath the desperate preoccupation of weight control. At another level, the moral control which self-denial brings in the form of limiting food intake and driving the body to the limits of its physical endurance should be seen as attempts to overcome a thoroughly low and degraded self-perception. Viewed in this way, it is possible to understand why anorexics are never satisfied with how thin they are and strive to lose more and more weight. 'I'll stop when I'm 6 stone' is a familiar warning light to anyone who works with anorexic clients, for at 6 stone, the goal changes to 5½. Franz Kafka's short story, The Hunger Artist, illustrates the profound sense of well-being which self-mortification can produce. The hunger artist in the story is a professional faster who travels around with his impresario amazing the crowds with his fasting feats. He is always unhappy and dissatisfied with himself because the impresario makes him stop fasting after 40 days. He feels he could achieve real self-satisfaction if only he was allowed to go on a little longer. As the story goes on, the world begins to change; fasting loses its public appeal and the hunger artist abandons his impresario. He makes his final
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fast as part of a circus menagerie, unwanted and forgotten. He finally confesses to the person who discovers him, dying, on a heap of straw, that he would have eaten long ago if only he could have found a food he liked. The fasting aspect of anorexia likewise has a life of its own. Self-satisfaction always seems to be around the next corner and to abandon self-control seems as though it would nullify everything which has gone before. Clearly, the road to self-respect through self-starvation is an endless one, because the goal doesn't really lie in that direction. The use of self-denial to achieve self-respect is particularly a feature of anorexia when there is also an overeating component to the pattern. The woman 'loses control', overeats, feels she has indeed become the wretched, indulgent, sinful creature she feared she might be and once again has no option but to fast to regain self-esteem. The physiological effects of fasting, in particular 'the fasting high' or euphoria, as described by Shirley Ross (1978), also play a part here. Fasting does in itself produce a psychological feeling of well-being in contrast to the uncomfortable, sluggish dull feelings which are brought about by overeating. There is no doubt that anorexics (even those who sometimes overeat) are real mistresses of self-control. My clients are well aware of the envy they often induce in other people and the fascination which their self-control engenders. They find it even more rewarding that this kind of admiration is not usually expressed and that envy often takes the form of admonishments or threats. The typical example would be a couple of nurses who spend an hour trying to force an anorexic to eat her pudding, finally end up shouting at her that she's a little fool who doesn't know what's best for herself. They then walk back to the office, patting their stomachs and saying they don't know how she does it and if only they could lose some weight like her ! This kind of envy arouses very competitive feelings towards anorexics from other women and in hospital wards they are usually intensely unpopular with the other patients. Given this state of affairs, it comes as a curious shock to realize that what brings anorexics to therapy (by this I mean a voluntary asking-for-help) is the conviction that they are out of control. Universally they claim that they cannot control what is happening to them, whether this be over-eating, under-eating or a combination of the two. I have had two clients (both of a religious disposition) who firmly believed that they were in the grip of some evil demon which tormented them whenever they attempted to eat. Ellen West describes how she longs to eat 'harmlessly', not to be ravaged by her compelling need to control every morsel which passes her lips. Most anorexics who come to therapy have already been taught to see their inability to lessen their rigid control on their eating as an 'illness'. One of my clients, whom I first saw when her symptoms were passed their worst, described it thus: 'My willpower's stronger than I am'. None of the current textbooks on anorexia adequately describes the appalling unhappiness which the anorexic food-obsession causes. The feeling that nothing in life is straightforward and unproblematic. Waking up in the morning and instantly remembering that she ate some biscuits last night and is now faced with a decision about breakfast. Anorexics find it impossible to understand how anyone can possibly just eat without elaborate calorific calculations and endless soul searching as to whether it is the correct quantity or not. Rowena, aged 28, had had anorexia for 6 or 7 years. She was by this time a reasonable weight and had been pronounced cured by her doctors. She was however still tormented by the fear of putting on weight and knew the calorific values by heart of every food she ate. She wrote to me ' . . . more and more I am starting to dread that this self-inflicted slavery is forever and the drudgery and self-disgust is killing me as effectively as any abstinence from food could'.
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The reasons for this despair are two-fold. Firstly there is the irrational terror of getting fat. The smallest amount of food is perceived as having great power to produce fat. Closely allied to this is the fear of actually overeating, and never being able to stop. Secondly, there are the feelings of moral debasement and self-recrimination which always accompany eating. To continue with the paradox, the anorexic's attempts at self-control do, in fact, have a very controlling effect on other people. The horror for a family of seeing a daughter systematically starving herself and becoming more and more ill makes it quite impossible for them to treat her in any way 'normally'. They will go to any lengths to encourage her to eat. This may include cooking special food, organizing family mealtimes around her often bizarre eating requirements or even taking her out to a restaurant for every meal. One of my anorexic clients has not eaten a meal at home for the past 3 years. Every day she has lunch at a restaurant and her mother takes her out for an evening meal. This means that the mother is never at home to prepare an evening meal for the rest of the family and must always be available to take her daughter for a long car journey to a 'suitable' restaurant after a long day's work herself. Some writers have seen in the controlling effect of anorexia the key to the whole problem--Selvini-Palazzoli (1974) treats the problem as one of family dynamics and aims to break the anorexic's controlling hold over her family. The implication here is that the family and particularly the mother are responsible for the genesis of the problem. Selvin relies heavily on the work of Bateson et al. (1963) and attempts to formulate a picture of the 'Anorexic Family' in much the same way that Laing and Esterson (1964) do with the families of schizophrenics. They too rely heavily on Bateson's work on family communication in their analysis. While not wanting to discount this approach, I would put forward a note of caution. Mothers have in the past been held responsible for almost all of the ills which subsequently beset their children and many of these accounts no longer hold up to careful scrutiny. Lee Comer (1974) discusses the issue of so-called Maternal Deprivation and the charges which have been laid at the feet of mothers. Joyce Leeson and Judith Gray (1978) look at the way in which mothers were accused of causing childhood autism. It may well be that to look for the cause of anorexia solely within the family is to disregard the impact which woman's position in society has on her psychological life. Having said that, I should like again to reiterate that it is families and mothers in particular who bear the brunt of the suffering and anxiety which anorexia causes. In my view, it is quite impossible for a family with an anorexic member to behave in any way which even approximates to normality. I do not however want to say that the controlling effect of the symptoms of anorexia is merely coincidental. If anorexia is a means of trying to take control in a unilateral way, without engaging in interaction with other people, it cannot be coincidence that it finally has the opposite effect. My understanding of unconscious processes would lead me to believe that the anorexic symptom precisely reflects the ambivalence of the original conflict. The real issues about power and control lie between the woman and the outside world. She feels unable to tackle them at that level and makes control into an entirely internal problem, looking to self-control as a substitute of effective control of self, which requires interaction with other people. The fact that the control issues finally get thrown back to the immediate environment, and later to wider social control mechanisms via health specialists, is a true reflection of the nature and origin of the conflict. The controlling influence which the anorexic has upon her family is, of course, one which is entirely unhelpful to her. It goes no way towards solving the original dilemma and serves only to reinforce her guilt and dependence. I have said that anorexics are not able to face the issues involved in taking control of their own lives. I will try to point briefly to some of the reasons why this might be so. To do the
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topic justice would require at least another paper on the psychology of women. However, 1 will try to provide a few signposts. Firstly, women are encouraged to locate any difficulties they feel inside themselves rather than in the world. As Leeson and Gray (1978) point out, a woman who is dissatisfied with the life she has is likely to be labelled 'neurotic', and attempts are made to understand her distress in the light of her early experiences. The women who later develop anorexia are particularly liable to this kind of interpretation as they look on the face of it to come from a very privileged group. They tend to be fairly affluent and almost all do well educationally. They are seen as young women with the world at their finger-tips. It is difficult from this position to assert that all is not right with the world. Secondly, women who do have a relatively privileged position and who are capable of achieving quite highly often experience a lot of guilt about this. I have said that anorexics appear to be particularly concerned about social problems and the lot of others who are less fortunate than themselves. Jean Baker-Miller (1978) writes particularly well about the difficulties experienced by talented women in using and acknowledging their gifts. Selfdenial in other areas can be seen as paying the price of success. At the same time of course it has the effect of making success almost impossible. The final aspect of the paradox is the control from outside which anorexics provoke from the medical professions. Again, it is impossible here to do justice to the very complex relationship which exists between the problem of anorexia and the response of the doctors. There is no problem in psychiatry which arouses quite so much anger, hostility and desperation as anorexia nervosa. I have seen a number of young psychiatric registrars pledge themselves to the 'curing' of a particular anorexic and end up behaving in the most brutally authoritarian manner! Part of the problem is that doctors' therapeutic goals usually centre around regaining weight without sufficient regard for the issues which cause weight loss in the first place. More importantly, I think, doctors fail to understand the paradox. They see anorexics as young women who are exercising too much self-control. They simply don't take account of the intense feelings of being out of control which accompany this. Thus, therapeutic intervention for them is based on breaking the control. Hilde Bruch (1978) explores carefully the catastrophic results which can occurr if this process is too forcibly carried out. In a condition in which the real issues are about self-government and regulation, any regime which merely takes these functions over makes the issues much harder (sometimes impossible) to resolve later on. With an understanding of the control paradox it becomes clear that the only viable therapeutic stance is one which can accept both sides of the paradox and hold them both without trying to force a resolution. Psychotherapy has often been directed towards showing the woman how much control she really has. While this is undoubtedly a correct assessment, it is only half correct. She does have control but only in a totally limited area. The other side of the paradox, the feelings of having no control at all, remain devastatingly true. In a male-controlled world where women are debased and encouraged to experience their bodies as defiled, anorexia can be seen as a logical solution to the need for women to take control of their lives and themselves. However, it is a solution which is symptomatic of the desperate situation it seeks to rectify. It is a solution which is essentially self-destructive and which seeks to substitute selfcontrol for effective control of the world in which the woman exists.
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REFERENCES
Baker-Miller, Jean. 1978. Toward a New Psychology o f Women. Penguin, London. Bateson, G., Jackson, D. D., Haley, J. and Weakland, J. H. 1963. A note on the double bind. Family Process 2, 154. Binswanger, Ludwig. 1944. Der Fall Ellen West Schweizer. Arch. Neurol. Psychiat. 53, 255-277; 54, 69-117, 330-360; 55, 16-40. Translated by Mendel, Wm. and Lyons, J. 1958. In: May, R., Angel, E. and Ellenberger, H. eds. Existence. Basic Books, New York. Bruch, Hilde. 1974. Eating Disorders. Obesity, Anorexia Nervosa and the Person Within. Routledge & Kegan Paul, London. Bruch, Hilde. 1978. The Golden Cage. Open Books, London. Comer, Lee. 1974. Wedlocked Women. Feminist Books, Leeds. France, Anatole. 1890. Thais. Translated by Chapman, F. and May, J. L. Bodley Head, London. Huxley, A. 1958. Chrome Yellow. Chatto & Windus, London. Kafka, Franz. 1948. The Penal Colony. Schocken Books, New York. Laing, R. D. and Esterson, A. 1964. Sanity, Madness & the Family. Tavistock, London. Leeson, Joyce and Gray, Judith. 1978. Women & Medicine. Tavistock, London. Mensching, Gustav. 1976. Structures & Patterns o f Religion. Translated by Klimheit, H. F. and Sarma, Srinivasa, Banarsidass, V. Delhi. Orbach, Susie. 1978. Fat is a Feminist Issue. Paddington Press, London. Ross, Shirley. 1976. Fasting. Sheldon Press, London. Selvini-Palazzoli, Mara. 1974. Chaucer, London. Waddell, Helen. 1936. (Trans.) The Desert Fathers. Constable, London. Weber, Max. 1965. The Sociology o f Religion. Methuen, London.
ANOREXIA NERVOSA--THE CONTROL PARADOX MAR1LYN LAWRENCE
School of Applied Social Studies, University of Bradford, Bradford BD7 1DP, U.K. (Received and accepted January 1979)
Synopsis--Thispaper examines the Control Paradox which is at the centre of anorexia nervosa. The paradox consists in the very powerful control which anorexics exert in the area of food and weight and their own experience of themselves as utterly out of control. Anorexics are attempting to solve the problem of their own powerlessness and denigration as women by engaging in an internal struggle for self-control. The struggle takes the form of an effort to transcend the body which debases them, and to achieve self-respect through self-denial.
I n this paper I want to draw attention to the central paradox o f anorexia nervosa, and look at some o f its meanings and implications. I have called it The Control Paradox and stated briefly it involves the following contradictory statements. (1) Anorexics achieve perfect and absolute control at two levels: (a) control of size and shape, i.e. physical, and (b) control in the sense o f self denial, i.e. moral. In the course o f (a) and (b) they also have a controlling effect on other people a r o u n d them. However (2) anorexics experience themselves as entirely out o f control at two levels: (a) they are terrified of becoming fat--physical; and (b) they see themselves as gluttonous and d e b a s e d - - m o r a l . They give themselves over to doctors to be controlled, thus defining (1) as well as (2) as illness. T h r o u g h o u t the paper I will refer to the anorexic as 'she'. There are a few male anorexics. Hilde Bruch (1974) has a research sample of 1 0 ~ b u t it is overwhelmingly a problem which afflicts w o m e n and these are almost all women who have achieved highly in education. To begin, I should like to explain a little o f what is meant by control. The term control is obviously related to the term power, in the sense o f potency and force. In this sense it has the meaning o f power over something or someone. We do not normally use the term 'selfpower' in the sense of possessing the ability to force oneself. We would be much more likely to use the term 'self-control'. It is m y contention that m a n y of the issues underlying anorexia are crucially related to the use of these two terms. In order for an individual to be free to direct herself and take charge of her own actions, it is necessary for her to engage with other people in such a way that the interaction allows her this control. It m a y be necessary for her to exercise some power in relation to other people. W h e n anorexics talk about control, they invariably mean the power to regulate, c o m m a n d and govern their own lives and actions. They generally fail to do this by turning outwards and engaging with the world on their own behalf. Instead, they exercise self-control, which we might understand as power turned inwards. The battleground then becomes an internal one; the battle is fought within the individual rather than between the individual and the world. 93
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Paradoxically, this self-control does finally achieve what the woman herself has been unwilling to a t t e m p t - - i t has a controlling effect on her environment. An anorexic family member has a great deal of power in terms of the organization of the family around h e r symptom. Ultimately though, this power will be taken away. The 'symptom' is diagnosed, she is recognized to be ill and taken into hospital where she is controlled from outside herself. At the level of behaviour, the key feature of anorexia is an unshakeable desire to control both food intake and weight. The psychological need to control weight and to be thin are c o m m o n enough preoccupations amongst women in general. Clearly, this is related to the pressures upon women to conform physically to a culturally-defined stereotype which, at present, revolves strongly around thinness. It is also directly due to the tendency to assume that any difficulties in a woman's life can and should be solved by her changing herself in order to 'fit'. W o m e n are often encouraged to make physical changes in themselves in order for life to be better. New clothes, a new hair-style, a 'face-lift' are advocated not only by husbands but often by doctors too as a solution to women's depression. How many women have not at some time or other believed that life would really be better if only they could lose a stone in weight? Thus, controlling weight is used by many women as a substitute for controlling the real issues in their lives over which they have no control. This is well described by Susie Orbach (1978) in her chapter ' W h a t is thin about?' Hilde Bruch (1978) was the first writer on anorexia to point out that the need to control is a central feature of anorexia and that not far below the perfectly-controlled surface lie terrifying feelings of lack of control. Hilde Bruch calls it a 'paralysing sense of ineffectiveness'. These fears of total loss of control centre around the area of food. ' I ' m afraid to pass the cake shop in case the smell makes me lose control'; this fear was expressed by a w o m a n who had not deviated from her daily ration of 2 oz of cheese and a couple of lettuce leaves for 3 years. These fears also spread out into all other areas of life as well. One of my former clients, Sandra, who developed the problem soon after gaining a first-class degree in history, woke her mother early one morning demanding to be shown how to operate the automatic washing machine. She was tormented by the thought that if her mother were ever ill, she would not know how to work the thing and was terrified of being lefthelpless with it. Controlling her size and her food intake was for Sandra only one aspect of the need to control the environment as a whole. Sandra was unable at that time to face the real issues which were confronting her in her life. Her family had not only high academic expectations for her future, but also saw her as a person with the highest possible moral and human qualities. Sandra was, without conscious protest, being projected towards a life of social usefulness and self-sacrifice. This sense of a total inability to control the environment is compensated for by a desperate attempt to control the self in the environment. Anorexics appear to need to separate themselves from the environment. They need to define their own limits and set boundaries around themselves. The setting of boundaries around the self is a difficult problem for women as they are at least in part regarded as an aspect of the environment of others. W o m a n is the caret, the facilitator, receptive and waiting to allow herself to become 'something' in someone else's life. Being very thin seems to say to the world 'I have sharp contours, I am not soft, I do not merge with you. I have nothing to give you'. A recovered anorexic vividly described her anorexic experience to me in terms of 'needing to be closed up for a while, and very small. N o t receptive, not there for others'. I have mentioned that attempts at size and weight control are common features of
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women's attempts to adapt themselves to fit when life seems uncomfortable. Less common is the emphasis which anorexics put on rigid control of actual food intake. Control of eating becomes split off from control of weight and is in itself a separate activity. Weight control is the tangible proof that eating control is effective. I would like to stress the often disregarded moral dimension of anorexia. Too often, the aim of anorexia is thought to be slimming alone. It is regarded as a silly cosmetic obsession. The rigid control of food intake is, I think, more properly regarded as a kind of asceticism. In our culture, people are frequently taught to regard self-denial as a 'good' thing. However, it is a particularly 'good' thing for women, as it is women who are more inherently prone to badness and moral weakness. Eating is frequently put on a moral par with law-breaking or sexual transgression ('it's illegal, it's immoral or it makes you fat' !) Self-denial in the area of food will therefore bring with it some fairly far-reaching moral kudos, and will be an indicator of moral worth. In fact, anorexics engage in a number of other ascetic activities in addition to food limitation. Almost all subject themselves to violent over-exercise and tax their bodies to the very limits of physical endurance. Some also refuse to wrap themselves up in cold weather, feeling it is a sign of strength to force the body to withstand extremes of cold. Some anorexics (and chronic 'slimmers' too!) believe that the body burns up more calories if it is not protected from the cold and so not wearing warm clothes is also an attempt to lose more weight. It seems that losing weight and thus becoming attractive and acceptable must always be associated with some form of selfmortification. Gustav Mensching (1976) describes the purpose of the practices of asceticism as 'freeing the soul out of the prison of the body'. He talks about the dualism of body and soul which is a prerequisite for asceticism. The ascetic must fail to identify her true self with the body which she mortifies. In Weber's (1965) analysis of asceticism, the world-rejecting ascetic makes an identification between the world which is essentially sinful, and the body which attempts to keep the soul bound to the world. In order for the soul to overcome and transcend the base and wretched world, it must first subdue and overcome the body which is its prison. If we consider the history of women in religious life, we see that this dualism of body and soul is a fundamental necessity. Woman's body is regarded as essentially sinful, defiled and defiling. Moral perfection for woman can only be approached by the total denial and denigration of her body. In Helen Waddell's (1936) translation of the stories of the Desert Fathers, a number of Desert Mothers are also mentioned, terrifying achoresses whose selfmortification is blood-curdling. The point of particular interest is that most of the anchoresses mentioned are reformed prostitutes, while the anchorites appear to have been saints from birth. Even St. Mary, niece of Abraham the Hermit, who spent her first 20 years in utter purity has to go off and live as a'whore for 2 years before she can fully commit herself to the subduing and mortifying of her body. Women must, if they are to achieve spirituality and moral justification, experience and acknowledge the total sinfulness and moral disgrace of their own bodies. The ascetic rigours of the anchoress were thus carried out in the midst of overwhelming and terrifying guilt about their very nature and being. St. Pelagia, again a harlot, lived for many years as a desert hermit masquarading as a man. It was only after her death when the monks came to anoint the hermit's body, that her feminity was revealed. The monks were astonished that a woman could have achieved such sanctity. Maybe Pelagia knew that a woman could not have done. At any rate, her quest for moral perfection led her to the abandonment of her femininity. The most dreadful story of all the anchoresses is that of Thais, the story on which the
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novel Thais by Anatole France (1890) was based. Thais, the most sought-after courtesan in Alexandria is converted by the holy man Paphnutius. In order to establish her true penitence, he seals her up in a filthy, doorless cell to contemplate the despicable state of her soul. Three years later, he returns and drags her from her foul prison, although she begs to be allowed to stay. Within 2 weeks she is dead. What better illustration of man's need to punish woman for being what he demands that she be. One can hardly do better on this point than to follow Jean Baker-Miller's (1978) excellent arguments that woman's territory is essentially that of man's unresolved problems. Issues with which the dominant culture has never come to terms e.g. sexuality, death, emotion, are handed over to be the domain of woman. Thus man is enabled to exorcise a demon of his own by punishing woman for her sexuality. Asceticism for women then is an attempt to attain spirituality or goodness or moral strength or power by punishing and subduing that part of them which is both weak and sinful, their bodies. Here is a short extract from Ellen West, the case of an anorexic woman written up by Binswanger (1944): 'In the diary she continues to air her hatred of the luxury of good living which surrounds her. She bemoans her cowardice and weakness in not being able "to rise above the conditions", in letting herself at so early an age be made flabby by the ugliness and the stuffy air of the every day.' Ellen only feels morally justified when she is abusing her body most appallingly. 'She arrives completely emaciated, with trembling limbs and drags herself through the summer, a physical torment, but feels spiritually satisfied because she is thin. She has the feeling that she has found the key to her well-being.' In my experience few anorexics will account for their actions directly in spiritual or religious terms, though I have found a surprisingly high rate of religious affiliation and outlook amongst my anorexic clients. Most, however, express feelings about themselves very much like those of Ellen West. There is a general feeling that the world is a bad place. Most of my clients had what might be called a strong 'social conscience', and a well worked out view of what their role in social reconstruction should be. Coupled with this is the feeling that self too is very bad, every bit as bad as the world it would like to change. Clearly this relates directly to the position in which society places women, and to the taboos and denigrating explanations with which it surrounds them. The self-disgust which a woman learns for her normal bodily processes, such as pregnancy and menstruation; the 'choice' of labels to describe her sexuality (e.g. 'whore' or 'virgin'--'tight' or 'loose'); it is not difficult to understand why women associate their bodies with difilement and badness. Anorexia can then be seen as a logical strategy for denying this defilement and rising above it. The methods used are almost precisely those used by the Desert Mothers to achieve the same ends. The self-controlling aspects of anorexia, are, I think, less puzzling if we begin to see them in the light of other aspects of human experience which we are able to understand. I have talked about weight control for cosmetic reasons and weight control for ascetic reasons as though these were unrelated. In fact I should now like to suggest that they have quite a complex relationship. The idea of woman only achieving moral justification through intense physical self-control is so deeply entrenched in our consciousness that an important aspect of attractiveness or desirability in a woman is centred on her ability to deny herself. This is obviously true in the area of chastity. The woman must be warm and passionate with her chosen map., but is admired by him only if she has succeeded in denying
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and subduing her sexual feelings up to that point. This is obviously related to the ownership of women, but it is also found in, for example, the eroticism of the cult of the Virgin Mary. Her erotic attraction lies precisely in her virginity and more especially in the fact of her having borne a child without any of the 'pleasures' usually associated with its conception. There is no doubt that self-denial in the area of eating is also a source of attractiveness and desirability. Eating, especially in large quantities is an unseemly activity for women. The attractiveness of self-denial and spirituality in women is beautifully illustrated in Aldous Huxley's Crome Yellow with the story of the three Miss Lapiths. When George Wimbush goes for dinner with the Lapith family, he is struck both by the beauty of the three daughters and by the fact that they do not eat. He comments on their lack of a p p e t i t e . . . 'Pray, don't talk to me of eating', said Emmeline, drooping like a sensitive plant, 'we find it so coarse, so unspiritual, my sisters and I. One can't think of one's soul while one is eating ! ' . . . 'For his part, he thought them wonderful, wonderful, especially G e o r g i a n a . . . Georgiana was the most ethereal of all; of the three she ate the least, swooned most often, talked most of death and was the palest . . . . At any moment it seemed she might lose her precarious hold on this material world and become all spirit.' Mr. Wimbush continues to adore his ethereal and unattainable Georgiana until one day by accident he comes upon a secret stairway which leads to a room where he finds the Miss Lapiths--eating! He blunders out in horror and Georgiana is so ashamed that she agrees to marry him to ensure his silence. Many anorexics, while being able either to eat small quantities or even to overeat on their own, are quite unable to eat in front of other people. Most 'normal' women also overeat. But this is almost always done secretly and possibly confessed to other women. It is never an area of their lives which women share with men. It seems to be important for women not to be seen to need food in the way in which men need it. Indeed it seems that under-eating is an integral part of the 'feminine' image. Part of attracting men is pretending not to be human. This is reminiscent of the ascetic's aspirations to transcend her human nature by her austerities. The theme of control then, works at a number of levels of anorexia. Control of size and shape is seen as a means of taking charge of a world which is uncontrollable. The real issues which confront all women around control of their lives and ownership of themselves are lost beneath the desperate preoccupation of weight control. At another level, the moral control which self-denial brings in the form of limiting food intake and driving the body to the limits of its physical endurance should be seen as attempts to overcome a thoroughly low and degraded self-perception. Viewed in this way, it is possible to understand why anorexics are never satisfied with how thin they are and strive to lose more and more weight. 'I'll stop when I'm 6 stone' is a familiar warning light to anyone who works with anorexic clients, for at 6 stone, the goal changes to 5½. Franz Kafka's short story, The Hunger Artist, illustrates the profound sense of well-being which self-mortification can produce. The hunger artist in the story is a professional faster who travels around with his impresario amazing the crowds with his fasting feats. He is always unhappy and dissatisfied with himself because the impresario makes him stop fasting after 40 days. He feels he could achieve real self-satisfaction if only he was allowed to go on a little longer. As the story goes on, the world begins to change; fasting loses its public appeal and the hunger artist abandons his impresario. He makes his final
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fast as part of a circus menagerie, unwanted and forgotten. He finally confesses to the person who discovers him, dying, on a heap of straw, that he would have eaten long ago if only he could have found a food he liked. The fasting aspect of anorexia likewise has a life of its own. Self-satisfaction always seems to be around the next corner and to abandon self-control seems as though it would nullify everything which has gone before. Clearly, the road to self-respect through self-starvation is an endless one, because the goal doesn't really lie in that direction. The use of self-denial to achieve self-respect is particularly a feature of anorexia when there is also an overeating component to the pattern. The woman 'loses control', overeats, feels she has indeed become the wretched, indulgent, sinful creature she feared she might be and once again has no option but to fast to regain self-esteem. The physiological effects of fasting, in particular 'the fasting high' or euphoria, as described by Shirley Ross (1978), also play a part here. Fasting does in itself produce a psychological feeling of well-being in contrast to the uncomfortable, sluggish dull feelings which are brought about by overeating. There is no doubt that anorexics (even those who sometimes overeat) are real mistresses of self-control. My clients are well aware of the envy they often induce in other people and the fascination which their self-control engenders. They find it even more rewarding that this kind of admiration is not usually expressed and that envy often takes the form of admonishments or threats. The typical example would be a couple of nurses who spend an hour trying to force an anorexic to eat her pudding, finally end up shouting at her that she's a little fool who doesn't know what's best for herself. They then walk back to the office, patting their stomachs and saying they don't know how she does it and if only they could lose some weight like her ! This kind of envy arouses very competitive feelings towards anorexics from other women and in hospital wards they are usually intensely unpopular with the other patients. Given this state of affairs, it comes as a curious shock to realize that what brings anorexics to therapy (by this I mean a voluntary asking-for-help) is the conviction that they are out of control. Universally they claim that they cannot control what is happening to them, whether this be over-eating, under-eating or a combination of the two. I have had two clients (both of a religious disposition) who firmly believed that they were in the grip of some evil demon which tormented them whenever they attempted to eat. Ellen West describes how she longs to eat 'harmlessly', not to be ravaged by her compelling need to control every morsel which passes her lips. Most anorexics who come to therapy have already been taught to see their inability to lessen their rigid control on their eating as an 'illness'. One of my clients, whom I first saw when her symptoms were passed their worst, described it thus: 'My willpower's stronger than I am'. None of the current textbooks on anorexia adequately describes the appalling unhappiness which the anorexic food-obsession causes. The feeling that nothing in life is straightforward and unproblematic. Waking up in the morning and instantly remembering that she ate some biscuits last night and is now faced with a decision about breakfast. Anorexics find it impossible to understand how anyone can possibly just eat without elaborate calorific calculations and endless soul searching as to whether it is the correct quantity or not. Rowena, aged 28, had had anorexia for 6 or 7 years. She was by this time a reasonable weight and had been pronounced cured by her doctors. She was however still tormented by the fear of putting on weight and knew the calorific values by heart of every food she ate. She wrote to me ' . . . more and more I am starting to dread that this self-inflicted slavery is forever and the drudgery and self-disgust is killing me as effectively as any abstinence from food could'.
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The reasons for this despair are two-fold. Firstly there is the irrational terror of getting fat. The smallest amount of food is perceived as having great power to produce fat. Closely allied to this is the fear of actually overeating, and never being able to stop. Secondly, there are the feelings of moral debasement and self-recrimination which always accompany eating. To continue with the paradox, the anorexic's attempts at self-control do, in fact, have a very controlling effect on other people. The horror for a family of seeing a daughter systematically starving herself and becoming more and more ill makes it quite impossible for them to treat her in any way 'normally'. They will go to any lengths to encourage her to eat. This may include cooking special food, organizing family mealtimes around her often bizarre eating requirements or even taking her out to a restaurant for every meal. One of my anorexic clients has not eaten a meal at home for the past 3 years. Every day she has lunch at a restaurant and her mother takes her out for an evening meal. This means that the mother is never at home to prepare an evening meal for the rest of the family and must always be available to take her daughter for a long car journey to a 'suitable' restaurant after a long day's work herself. Some writers have seen in the controlling effect of anorexia the key to the whole problem--Selvini-Palazzoli (1974) treats the problem as one of family dynamics and aims to break the anorexic's controlling hold over her family. The implication here is that the family and particularly the mother are responsible for the genesis of the problem. Selvin relies heavily on the work of Bateson et al. (1963) and attempts to formulate a picture of the 'Anorexic Family' in much the same way that Laing and Esterson (1964) do with the families of schizophrenics. They too rely heavily on Bateson's work on family communication in their analysis. While not wanting to discount this approach, I would put forward a note of caution. Mothers have in the past been held responsible for almost all of the ills which subsequently beset their children and many of these accounts no longer hold up to careful scrutiny. Lee Comer (1974) discusses the issue of so-called Maternal Deprivation and the charges which have been laid at the feet of mothers. Joyce Leeson and Judith Gray (1978) look at the way in which mothers were accused of causing childhood autism. It may well be that to look for the cause of anorexia solely within the family is to disregard the impact which woman's position in society has on her psychological life. Having said that, I should like again to reiterate that it is families and mothers in particular who bear the brunt of the suffering and anxiety which anorexia causes. In my view, it is quite impossible for a family with an anorexic member to behave in any way which even approximates to normality. I do not however want to say that the controlling effect of the symptoms of anorexia is merely coincidental. If anorexia is a means of trying to take control in a unilateral way, without engaging in interaction with other people, it cannot be coincidence that it finally has the opposite effect. My understanding of unconscious processes would lead me to believe that the anorexic symptom precisely reflects the ambivalence of the original conflict. The real issues about power and control lie between the woman and the outside world. She feels unable to tackle them at that level and makes control into an entirely internal problem, looking to self-control as a substitute of effective control of self, which requires interaction with other people. The fact that the control issues finally get thrown back to the immediate environment, and later to wider social control mechanisms via health specialists, is a true reflection of the nature and origin of the conflict. The controlling influence which the anorexic has upon her family is, of course, one which is entirely unhelpful to her. It goes no way towards solving the original dilemma and serves only to reinforce her guilt and dependence. I have said that anorexics are not able to face the issues involved in taking control of their own lives. I will try to point briefly to some of the reasons why this might be so. To do the
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topic justice would require at least another paper on the psychology of women. However, 1 will try to provide a few signposts. Firstly, women are encouraged to locate any difficulties they feel inside themselves rather than in the world. As Leeson and Gray (1978) point out, a woman who is dissatisfied with the life she has is likely to be labelled 'neurotic', and attempts are made to understand her distress in the light of her early experiences. The women who later develop anorexia are particularly liable to this kind of interpretation as they look on the face of it to come from a very privileged group. They tend to be fairly affluent and almost all do well educationally. They are seen as young women with the world at their finger-tips. It is difficult from this position to assert that all is not right with the world. Secondly, women who do have a relatively privileged position and who are capable of achieving quite highly often experience a lot of guilt about this. I have said that anorexics appear to be particularly concerned about social problems and the lot of others who are less fortunate than themselves. Jean Baker-Miller (1978) writes particularly well about the difficulties experienced by talented women in using and acknowledging their gifts. Selfdenial in other areas can be seen as paying the price of success. At the same time of course it has the effect of making success almost impossible. The final aspect of the paradox is the control from outside which anorexics provoke from the medical professions. Again, it is impossible here to do justice to the very complex relationship which exists between the problem of anorexia and the response of the doctors. There is no problem in psychiatry which arouses quite so much anger, hostility and desperation as anorexia nervosa. I have seen a number of young psychiatric registrars pledge themselves to the 'curing' of a particular anorexic and end up behaving in the most brutally authoritarian manner! Part of the problem is that doctors' therapeutic goals usually centre around regaining weight without sufficient regard for the issues which cause weight loss in the first place. More importantly, I think, doctors fail to understand the paradox. They see anorexics as young women who are exercising too much self-control. They simply don't take account of the intense feelings of being out of control which accompany this. Thus, therapeutic intervention for them is based on breaking the control. Hilde Bruch (1978) explores carefully the catastrophic results which can occurr if this process is too forcibly carried out. In a condition in which the real issues are about self-government and regulation, any regime which merely takes these functions over makes the issues much harder (sometimes impossible) to resolve later on. With an understanding of the control paradox it becomes clear that the only viable therapeutic stance is one which can accept both sides of the paradox and hold them both without trying to force a resolution. Psychotherapy has often been directed towards showing the woman how much control she really has. While this is undoubtedly a correct assessment, it is only half correct. She does have control but only in a totally limited area. The other side of the paradox, the feelings of having no control at all, remain devastatingly true. In a male-controlled world where women are debased and encouraged to experience their bodies as defiled, anorexia can be seen as a logical solution to the need for women to take control of their lives and themselves. However, it is a solution which is symptomatic of the desperate situation it seeks to rectify. It is a solution which is essentially self-destructive and which seeks to substitute selfcontrol for effective control of the world in which the woman exists.
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REFERENCES
Baker-Miller, Jean. 1978. Toward a New Psychology o f Women. Penguin, London. Bateson, G., Jackson, D. D., Haley, J. and Weakland, J. H. 1963. A note on the double bind. Family Process 2, 154. Binswanger, Ludwig. 1944. Der Fall Ellen West Schweizer. Arch. Neurol. Psychiat. 53, 255-277; 54, 69-117, 330-360; 55, 16-40. Translated by Mendel, Wm. and Lyons, J. 1958. In: May, R., Angel, E. and Ellenberger, H. eds. Existence. Basic Books, New York. Bruch, Hilde. 1974. Eating Disorders. Obesity, Anorexia Nervosa and the Person Within. Routledge & Kegan Paul, London. Bruch, Hilde. 1978. The Golden Cage. Open Books, London. Comer, Lee. 1974. Wedlocked Women. Feminist Books, Leeds. France, Anatole. 1890. Thais. Translated by Chapman, F. and May, J. L. Bodley Head, London. Huxley, A. 1958. Chrome Yellow. Chatto & Windus, London. Kafka, Franz. 1948. The Penal Colony. Schocken Books, New York. Laing, R. D. and Esterson, A. 1964. Sanity, Madness & the Family. Tavistock, London. Leeson, Joyce and Gray, Judith. 1978. Women & Medicine. Tavistock, London. Mensching, Gustav. 1976. Structures & Patterns o f Religion. Translated by Klimheit, H. F. and Sarma, Srinivasa, Banarsidass, V. Delhi. Orbach, Susie. 1978. Fat is a Feminist Issue. Paddington Press, London. Ross, Shirley. 1976. Fasting. Sheldon Press, London. Selvini-Palazzoli, Mara. 1974. Chaucer, London. Waddell, Helen. 1936. (Trans.) The Desert Fathers. Constable, London. Weber, Max. 1965. The Sociology o f Religion. Methuen, London.