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European Eating Disorders Review
Eur. Eat. Disorders Rev. (in press)
Eating One’s Words, Part II:The Embodied Mindand Reflective Function inAnorexia Nervosa—Theory

*Correspondence to: Professor Finn SkardeEating Disorders, Kirkeveien 64 B, 0364Tel: þ47 918 19 990.E-mail: [email protected]

Copyright # 2007 John Wiley & Sons, Ltd a

Published online in Wiley InterScience (www

Finn Skarderud1,2*1Faculty of Health and Social Studies, Lillehammer University College, Norway2Centre for Child and Adolescent Mental Health, Eastern and SouthernNorway, Oslo, Norway

Anorexia nervosa as a psychiatric disorder presents itself throughthe concreteness of symptoms. Emotions are experienced as acorporeality here-and-now. In a companion article, Part I, different‘body metaphors’ are described and categorised. The human bodyfunctions as metaphor, and in anorexia nervosa there is a strikingcloseness between emotions and different bodily experiences. Thisis interpreted as impaired ‘reflective function’, referring to thecapacity to make mental representations, and is proposed as acentral psychopathological feature. The psychodynamic concepts‘concretised metaphors’ and ‘psychic equivalence’ are discussed asuseful tools to better understand such compromised symboliccapacity. Psychotherapy in anorexia nervosa can be described asa relational processwhere concretisedmetaphorswill be developedinto genuine linguistic ones. Part III in this series of articlespresents an outline for psychotherapy for anorexia nervosa.Copyright # 2007 John Wiley & Sons, Ltd and Eating DisordersAssociation.

Keywords: anorexia nervosa; embodiment; metaphor; mentalisation; psychoanalysis

INTRODUCTION

This text is the second of three companion articlesaiming to further the understanding of the specificpsychopathology in anorexia nervosa. Despiteresearch efforts anorexia nervosa still qualifies forthe designation as an enigma. The topic in thissecond part is ‘reflective function’ in anorexianervosa. Reflective function refers to the psycho-

rud, Institute forOslo, Norway.

nd Eating Disorders

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logical processes underlying the capacity to makemental representations, and has been describedboth in the psychoanalytic (Fonagy, 1989) andcognitive (e.g. Morton & Frith, 1995) psychologyliteratures.The empirical Part I (Skarderud, 2007a) was an

interview study with adult patients. A key conceptis ‘metaphor’. Part I describes, based on categoris-ation of the patients’ statements about food andtheir own bodies, how bodily sensations andattributes also function as a source area formetaphor production, giving form and expressionto emotions and cognitions. Physical qualities andsensations give form and content to non-physical

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phenomena. Consequently this does not point tolinguistic metaphors about the body as such, butdescription in verbal language about how bodilysensations and qualities like hunger, size, weightand shape are physical entities that represent alsonon-physical phenomena.The body as a source for metaphors is a general

human phenomenon. However, the overall findingin the interview study, and proposed as animportant trait in the psychopathology of anorexianervosa, is the patients’ reports of the closeness, themore or less immediate connection betweenphysical and psychological realities; the bodilyconcretised feelings here-and-now. In Part I theconcept ‘concretised metaphors’ is introduced todescribe such phenomena. A comprehensive defi-nition of this concept will follow (Enckell, 2002).This again refers to how one striking clinicalfeature—and a main limitation to therapy—inanorexia nervosa is the concreteness of symptoms.Many persons with anorexia nervosa experience thehere-and-now of their bodies as a ruthless realitydifficult to escape from.The results presented in Part I demonstrate such

concreteness, and this is interpreted as an impair-ment of reflective function, more specificallyreduced metaphorical capacity. This induced asystematic search for relevant literature. The mainpurpose of this article is to develop a theoreticalframe to explain and comprehend the empiricalfindings. In this Part II of the presentation the mainemphasis is on theoretical models describingcompromised reflective function, and relating thisto anorexia nervosa. Special importance is placed onpsychodynamic models of the body’s role inmetaphorical processes. Part III in this series ofarticles presents an outline for psychotherapy foranorexia nervosa (Skarderud, 2007b).

THE THEORY OF METAPHOR

The essence of the metaphor is to understand andexperience one phenomenon through anotherphenomenon. In the last decades there has been agrowing interest for developing theories aboutmetaphor. This applies to a number of professionaltraditions outside literary science. The metaphorhas been extensively applied within cognitivescience, philosophy and the philosophy of science.Since the early 1980s there has been significantinterest in metaphor in psychoanalytic circles, bothin terms of psychodynamic theory and practice(Enckell, 2002).

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders A

The Bodily Mind

According to the French phenomenologist philoso-pher Maurice Merleau-Ponty (1907–1961) (1964,p. 390) all linguistic signification is ultimatelymetaphorical. The philosophers Mark Johnsonand George Lakoff have been the leading figuresin terms of changing interpretations of metaphorfrom being purely a phenomenon in language, arhetoric or artistic figure of speech, to becoming amodel for the general function of mind. Accordingto them (1980): ‘Metaphor is typically viewed ascharacteristic of language alone, a matter of wordsrather than thought and action. For this reason,mostpeople think they can get along perfectly wellwithout metaphor. We have found, on the contrary,that metaphor is pervasive in everyday life, notjust in language but in thought and action. Ourordinary conceptual system, in terms of which wethink and act, is fundamentally metaphorical innature’ (p. 3).Johnson and Lakoff do not consider the metaphor

as the result of a conscious multi-stage process ofinterpretation. Rather, it is rather a matter ofimmediate conceptual mapping via neural connec-tions. It is an experientially grounded mapping,based on perception. The metaphor is pervasive forhuman understanding, fantasy and reason. Themetaphor is basic, but often not conscious. Hence,metaphors are part of the cognitive unconscious.Johnson (1987) states: ‘Metaphor is not only alinguistic mode of expression; rather, it is one of thechief cognitive structures by which we are able tohave coherent, ordered experiences that we canreason about and makes sense of’ (p. xi).The common effort of Johnson and Lakoff is

‘putting the body back into the mind’ (Johnson,1987; Lakoff & Johnson, 1999). Their work is arejection of the Cartesian dualism between bodyand soul. They state that there is no Cartesiandualistic person. They strongly argue against thetradition in Western philosophy that considerscognition and rationality as separated from ourbodily existence, as separated from perception andmovement. One essential concept is the embodiedmind. Mind is always and inevitably based onbodily perception and sensorimotor experiences.‘What is important is that the peculiar nature of ourbodies shapes our very possibilities for conceptu-alization and categorization’ (Lakoff & Johnson,1999). Amajor reference in their philosophical workon embodiment is the body philosophy of thephenomenologist Merleau-Ponty. The human bodyis more than a mechanical object responding to

ssociation. Eur. Eat. Disorders Rev. (in press)

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stimuli. The body is in continuous interaction withthe world, not as a ‘thing’, but as a relation. Thebody is always both object and subject, anexperienced and experiencing unity, intentionallyseeking meaning through movement and activity(Duesund & Skarderud, 2003; Merleau-Ponty,1962).Lakoff and Johnson further this understanding of

body as a primary experience through descriptionsof the role of perceptual and motoric systems in theforming of basic concepts, like concepts aboutcolour, space, structuring of events and basicemotions. To be alive presupposes categorisation.They describe how the sensorimotor structuring ofsubjective experiences in man is based on a processof categorisation where the metaphor is absolutelyessential. In their model of the function of mindthere are three premises: (1) The mind is inherentlyembodied, (2) Thought is mostly unconscious and(3) Abstract concepts are largely metaphorical(Lakoff & Johnson, 1999).The authors make a distinction between ‘primary

metaphors’ and ‘complex metaphors’. (These termsare not equivalent to ‘specific metaphors’ and‘compound metaphors’, developed by the authorto categorise bodymetaphors in anorexia nervosa inPart I.) They demonstrate how bodily experiences ofspace, direction, structure, smell, taste, hearing,movement, closeness and distance, similarity, etc.create the basis for primary metaphors (Fauconnier& Turner, 1994; Grady, 1997; Johnson, 1987;Narayanan, 1997). A concrete example is gravita-tion, which organises our lives in an up–down axis.‘More is up’. Prices are high, I am feeling up to ittoday, one feels on top. Statements about quantity,mood, control, social position have their basis in thesensorimotor domain of vertical orientation.Another example is the connection between experi-encing problems and the bodily sense of heaviness:To be burdened. It is heavy. Or how knowledge andunderstanding are based on our visual senses: ‘I seewhat you mean’ (Lakoff & Johnson, 1980, 1999).Such primary metaphors are acquired automati-

cally and unconsciously through what they termneural learning. We may be ignorant about them,but they are experienced as ‘real’. Bodily experi-ences are to a great extent universal, and thisexplains the similarity across the world of suchprimary metaphors. Thence, they may be furtherdeveloped in language, into linguistic conventionswemay be conscious about and use deliberately andwith control. Some primary metaphors will neverdevelop into words in language, but may beexpressed as gestures, rituals or art.


In complex metaphors the primary metaphorshave been woven together with cultural models,popular conceptions, belief systems and science.Many such complex metaphors are stable—in thesense of conventions. They constitute importantparts of our conceptual apparatus and of how wethink and feel. And according to the authors(Lakoff, 1997), they structure our dreams, and formthe basis for new metaphorical combinations, in artand in everyday life (Lakoff & Turner, 1989; Turner,1995).

Psychodynamic Theory and Practice

The works referred above have made a significantcontribution to the demonstration that cognition,language and human action are organised meta-phorically around interactional experiencesbetween our bodies and the world. Their main,though not exclusive, focus of attention is theirconceptualisation of one of the two unknowablesconfronting human understanding—external rea-lity. Psychodynamic theory and practice deal withthe task of understanding the other—internalreality. To understand internal reality means tounderstand a human being who not only knows,but who also feels that knowledge (Rizzuto, 2001).The mental experiential world is a representationalstructure, and the function of the mind is toproduce and elaborate representations. Psychody-namic theory is basically an instrument to beused for understanding how the mind workswith its representations, in order to handledemands originating both in the internal and theexternal.Many psychoanalytic authors have used the

theory of metaphor to investigate both theoreticaland clinical issues. Their writings move in differentdirections, and cover different areas. However, aunifying trait is their psychodynamic understand-ing of the metaphor, as an expression of thefunction ofmind. For contemporary psychoanalyticauthors the metaphor is not only a linguistic device,but also a model describing general psychicprocesses (Enckell, 2002).Rizzuto (2001) has written a state-of-the-art-article

on contemporary psychodynamic models of ‘bodilymind’ and metaphoric functioning. In her review ofrecent findings in neuroscientific research andtheories of metaphor she leans heavily on Johnsonand Lakoff. She states the necessity of making aclear distinction between the ‘metaphoric process’and actual linguistic metaphors. The metaphoricprocess is all-encompassing, and is essential to


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human life and culture. The process by whichmetaphors for external reality are constructed—understanding and experiencing one thing in termsof another—applies to internal reality as well. Shestates that body configurations are the basiccondition for the development of different levelsof representing. Early perceptions organise moreelaborate or later ones, and during developmentmuch representational material is accumulated,both consciously and unconsciously. According toRizzuto, the accumulated representations are thebuilding blocks for the construction of both externaland internal reality. The mind can be seen asmetaphorising the realities through the body.Rizzuto refers to Sharpe (1940), a psychoanalyst

and teacher of English literature, as a pioneer in herconceptualisation of metaphor as essential for thedynamic understanding of psychic experience. Shestates that ‘metaphor fuses sense experience andthought in language’. She starts from the idea thatpsychological development goes from the ‘physical’to the ‘metaphysical’, and writes that psycho-analytic therapy goes in the opposite direction:‘Our search when we listen to patients must be forthe physical basis and experience from whichmetaphorical speech springs’. For the adult thebodily origin of thought is often forgotten. But theanalyst can move ‘backwards’ to the long forgottenpsychophysical matrix embedded in the manifestmetaphoric expressions. A ‘revitalisation’ of meta-phoric expressions might thus lead to an originalsensual experience (Enckell, 2002; Sharpe, 1940).In the wake of Sharp’s pioneering work, a number

of authors have followed in her footsteps and evenmoved beyond the linguistic metaphor (Arlow,1979; Borbely, 1998; Enckell, 2002; Melnick, 1997;Ogden, 1997; Rizzuto, 2001). They have contributedwith descriptions of both the mind as generallymetaphorising, and also of psychotherapy as aninteraction where the understanding of metapho-rical processes can guide the therapeutic activity.According to Borbely (1998), psychoanalysis seesthe present in terms of the past and the past in termsof the present. It therefore relates past and presentmetaphorically to each other. Symptoms are seen asthe analysand’s damaged ability to metaphorisepast and present. By using interpretations, theanalyst helps the analysand to restore metaphoricalprocesses that have been interrupted in their flowfrom the past to the present and from the present tothe past.Enckell (2002) mentions dreams and transference

as two examples illustrating a view according towhich the mind works through the medium of


verbal and non-verbal metaphors. Unconsciousconfigurations are transferred to different mediawhere they find representations and hence actua-lisation. And he also reminds us of the etymologicalcloseness between Freud’s original German conceptof transference, Ubertragung, and the Greekmetaphor(Uber-tragung/meta-phoros). The translation intoEnglish might blur the fact that originally the wordswere identical.

CONCRETISED METAPHORS

Of particular interest in this paper, with reference toanorexia nervosa, are the metaphoric functions ofthe human body. One finds concretised metaphorsuseful as a superior concept. These concretisedmetaphors do not function mainly as representationscapable of containing an experience, but aspresentations experienced as concrete facts here-and-now and which are difficult to negotiate with.In the corporeality of concretised metaphors there isthe sense that this is the way things ‘really’ are, withfew ifs, ands or buts. The problem is to distinguishbetween the metaphor and the object or phenom-enon which is metaphorised. The ‘as if’ of themetaphor is turned into an ‘is’. The ‘as-if’ quality ofthe more abstract meaning of the metaphor is lostand it becomes an immediate concrete experience.Enckell (2002) reviews psychoanalytic literature

with a view to this concept. He refers to how it isgenerally acknowledged that psychotic personsand patients suffering from borderline conditions(Caruth&Ekstein, 1966)may form their experiencesin metaphors which are subjectively not acknowl-edged as such. A vignette described by Kitayama(1987) may be illustrative of this phenomenon. Apsychotic man complained about his sleeplessness.He could not fall asleep due to a continuing light.This man had called his former girlfriend ‘mysunshine’. It turned out that the thought of thegirlfriend kept the patient awake. This can bedescribed as a collapse of the capacity to usefunctioning metaphors.There is a general agreement among many

authors that such phenomena, here named con-cretised metaphors, represent a regression ofrepresentational functioning and/or an insufficientdevelopment of symbolic capacity. Campbell andEnckell (2002) propose that concretised metaphorscan be viewed as restitutional efforts. With refer-ence to two cases of violent men, they discuss suchconcrete presentation as a reaction to a threat of


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inner fragmentation, and an attempt to maintain acohesivemental configuration, albeit a concrete one.Within the psychoanalytic tradition of self-

psychology, Atwood and Stolorow (1984) discuss‘concretisation’ in persons with a vulnerable self-organisation. Different forms of stress may threatenthe integrity of the self, and through concretisationthese persons attempt to bolster their sense of self bytrying to strengthen the experience of beinggrounded in their own bodies. They defineconcretisation as ‘the encapsulation of structuresof experience by concrete, sensorimotor symbols’(p. 85). For patients faced with a threatening loss ofintegrity of the self and the concomitant loss of thesense of reality, ‘concretisation may serve toameliorate a disorienting sense of unreality byrestoring a sense of the real. Clinging to the concreteattitude is then a means of maintaining one’s senseof reality, of possessing an ordered and orderlyexistence’ (Josephs, 1989, p. 492).Other authors claim that concretised metaphors

create a distance to unpleasant experiences, andregard concretised metaphors as signs of essentialdistancing defences (Alexandrowicz, 1962; Caruth& Ekstein, 1966).

Concretised Metaphors in Eating Disorders

The phenomena here described are widelyaccepted as a corollary of psychotic or borderlinefunctioning. In this text I propose that they arealso a part of the anorectic experience. More thanthat, the concept of concretised metaphors is aparticularly relevant tool in describing the psycho-pathology of anorexia and also in understandinglimitations and difficulties in therapy.The precursor of this text, Part I, presents the

empirical results from interviews and therapysessions with 10-adult patients with anorexianervosa [REF]. That article gives numerousexamples of such concretised body metaphors.They are categorised by the author in two maincategories, ‘specific metaphors’ and ‘compoundmetaphors’. Both these categories have moresubcategories.Specific body metaphors are named so because

they so directly refer to one domain of physicalexperience relating to an emotional and cognitiveexperience, like pure food equalising purity,simplicity and certainty in living. This specificitymakes clear the equivalent relation betweenemotion/cognition and sensorimotor experience/behaviour. These metaphors refer to a rich diversityof meanings of self-starvation, again based in a


variety of bodily experiences, for example purity,spatiality and solidity.Compound body metaphors are more ‘global’

than the specific ‘local’ ones, and referring toemotional and cognitive experiences often referredto as central in anorexia nervosa, like the sense ofvulnerability and a threatened and overburdenedself, experiences of lack of control in differentrealms of life and low self-esteem inducing thefeeling of not deserving. The compound bodymetaphors can be based on a combination of morespecific body metaphors, that is the sense of controlcan refer to an empty stomach, a firm and solidbody, being thin and a feeling of purity. But what isconsidered as themain finding in thismain categoryof body metaphors, and similar to specific meta-phors, is the immediate relation between emotion/cognition and sensorimotor experience/behaviour.Within the psychoanalytical tradition of self

psychology, several authors (Barth, 1988; Chessick,1984/85; Geist, 1985, 1989; Goodsitt, 1997) arguethat persons with anorexia nervosa are basicallysuffering from a disorder of the self, and that theconcretistic symptoms essentially serve the functionof maintaining the cohesion and stability of a verytenuous sense of self.Buhl (2002) does not use the concept of con-

cretised metaphors, but ‘concretism’ when describ-ing more or less identical phenomena. She refers tothis concretism as a developmental fault, a ‘deficitpathology’ (Killingmo, 1989) characterised by aninadequately developed ability to distinguish andunderstand emotional states and needs. Buhldescribes serious eating disorders as manifestationsof disorders in the development of personality, witha reduced capacity for abstract thinking.The ‘concrete attitude’ is a pervasive trait in

patientswith anorexia nervosa, with the tendency tofocus concretely on food and weight (Miller, 1991).And there are numerous references to thesepatients’ tendencies to a notable deficiency in theirability to think abstractly about psychologicalissues, and being singularly devoid of psychologicalinsight (Bruch, 1973; Geist, 1985; Goodsitt, 1985).Although this concretism is adequately des-

cribed, there are few references to discussionsabout this phenomenonwith regard to the theory ofmetaphor and metaphorisation as a general func-tion of mind. Shaly (1987) refers to the treatment ofa bulimic patient, where the patient’s use of food/body metaphors, both in actual living and inlanguage, were extensive. Ritvo (1984) describes acase of an eating disordered man using laxatives tocontrol his feelings. His ability to expel something


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unpleasant made life sufficiently tolerable. After heevacuated his bowels, he had a feeling of goodness,enabling him to temporarily ignore the complexemotions left in him. Ritvo also discusses themetaphors used in verbal language by eatingdisordered patients. He refers to the psychoanalystLewin (1971) who applied Freud’s practical classi-fication of dreams to metaphors, dividing verballyexpressed metaphors into those ‘from above’ andthose ‘from below’. Metaphors ‘from above’ refer toobvious, readily intelligible and conventionalsources and are more easily analysed. Those ‘frombelow’ are more likely to come from sensorimotorexperiences in the body. On this basis, Ritvo arguesthat the body metaphors used by individuals witheating disturbances are rooted in persisting experi-ences of the body and may have little figurativeverbal accompaniment. They are very muchmetaphors ‘from below’, althoughmetaphors ‘fromabove’ may also be present.Rizzuto (2001) briefly refers to eating disorders in

her interesting ‘state-of-the-art’ article of contem-porary psychodynamic models on ‘bodily mind’andmetaphoric functioning. She refers to how thereis a ‘clinical restriction of language’ in manybulimics and anorexics; a minimal use of metaphorin language, following problems of identifyingcommon somatic reactions that accompany theexperience of a variety of affects. It is tempting tointerpret her as saying: The body speaks when thereis a lack of a good-enough verbal language toidentify and express emotions.In the literature one has not hitherto found any

systematic presentation of different body meta-phors in anorexia nervosa, referring to differentsensorimotor and physical experiences as sourcesfor metaphorical production of emotions andmeanings; and where these also are related toimpaired reflective function. Hence, the descrip-tions and categorisations presented in Part I areoriginal.

Psychic Equivalence

Different conceptual tools may cover more or lessthe same phenotypes. Bateman and Fonagy (2004)and Fonagy, Gergely, Jurist, and Target (2002) writein the tradition of contemporary psychoanalysisand revised attachment theory, seeking to integratescientific knowledge of psychological developmentwith clinical experience. Amajor theoretical conceptin their work is ‘mentalization’, as an aspect of‘reflective function’. Mentalisation is defined as thedeveloped ability to ‘read’ other people’s minds. By


doing this, children make people’s behaviourmeaningful and predictable. Their early experienceswith other people enable them to build up andorganise multiple sets of self-other representations.As they learn to understand other people’sbehaviour better, they become flexibly able toactivate the representation(s) from these multiplesets that are best suited to respond to particularinterpersonal transactions.‘Mentalization involves both a self-reflective and

an interpersonal component. In combination, theseprovide the child with a capacity to distinguishinner from outer reality, interpersonal mental andemotional processes from interpersonal communi-cations’ (p. 4). This ability, according to the authors,underlies the capacities for affect regulation,impulse control, self-monitoring and the experienceof self-agency—the building blocks of the organ-isation of the self.The infant’s and the young child’s early aware-

ness of mental states is characterised by theequation of the internal with the external. Whatexists in the mind must exist out there, andwhat exists out there must invariably also exist inthe mind. This is defined as ‘psychic equivalence’.Insecurity in attachment relationships is a signalof limitation in mentalising skills. Different psy-chopathological phenomena are understood ascompromised mentalising capacity, with psychicequivalence in older children, adolescents andadults as one possible mode. ‘Psychic equivalence,as a mode of experiencing the internal world, cancause intense distress, since the projection of fantasyto the outside world can be terrifying’ (p. 9).This theoretical construct can be considered as

another naming of more or less similar phenomenaas described by concretised metaphors. Fonagy andcolleagues do not explicitly discuss anorexianervosa, but there are a few references to eatingdisorders. ‘When psychic reality is poorly inte-grated, the body takes on an excessively central rolefor the continuity of the sense of self. This maybecome critical in adolescence, when changes inbody shape and function signify a far greaterchange in identity for these individuals than forthose whose psychological self-representation isdevelopmentally more advanced. Some adolescents(such as early-onset anorexics) experience existen-tial anxieties in relation to puberty: as if they haveceased to exist—have become different people.There is psychic equivalence between the experi-ence of body shape and its concrete parameters; tobe thinner is felt to be superior and is thereforesuperior’ (p. 405).


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Not having a clear sense of themselves fromwithin, these persons with impaired self-organisation need to find a sense of the self fromoutside, ‘through treating themselves as objects,literally rather than metaphorically, because the selfis experienced as a physical being without psycho-logical meaning’ (p. 406). The persistence of psychicequivalence contributes to specific physical statesacquiring exaggerated significance in relation to theself. Mental states, unable to achieve representationas ideas or feelings, come to be represented in thebodily domain. ‘Physical attributes such as weightcome to reflect states such as internal well-being,control, sense of self-worth, and so on, far beyondthe normal tendency for this to happen inadolescence’ (p. 405).To sum up, the concept of psychic equivalence

further develops and enriches the language aboutthe ‘anorectic deficit’.

LIMITATIONS IN PSYCHOTHERAPY

Summing up, the statements from the patients in PartI demonstrated the very concrete anddirect characterof many of the body metaphors in anorexia nervosa.It is striking how such statements point to a basic andclose relationship between emotion and physicalbody, a more or less ‘immediate translation’. In theseconcretised metaphors there is a closeness, a directanalogy and primary relation, between emotions anddifferent sensorimotor experiences. Emotionalexperiences are organised, and felt, based ondifferent domains of physical life, sensorimotorexperiences and bodily attributes. Emotions areconcretised. One example of a ‘simple metaphor’ isabout purity; a patient describes how the act of noteating, having an empty stomach, induces a sense ofemotional purity. Another example, a ‘compoundmetaphor’ is very well-known from clinical practice:The person with anorexia experiences how control-ling food and appetite gives the feeling of moregeneral control in one’s life.The human body is unavoidably metaphorical.

We all ascribe a symbolical meaning to it that goesbeyond the purely physical. We are able to reflectupon it to a certain degree, adopt an attitudetowards it and not in the least consider howmuch itshould control us in our everyday life. In anorexianervosa this process is unfree. Persons withanorexia nervosa themselves often experience theirpreoccupation with food, calories, weight and sizeas obsessional. Typically, the anorexic patient hasunfortunately little conscious awareness of the


metaphoric connections between her/his concretesymptoms and the underlying emotions andsense of self. The anorectic’s problem is not thatthinking is metaphorical but rather that she/he ispossessed by these concretised metaphors; that thepatient is ‘used by’ rather than using them criticallyin his/her thinking and acting.It is the statement of this study that concretised

metaphors, and psychic equation, as descriptiveconcepts that contribute to better understandings ofanorexia nervosa. Among other, they guide us ingrasping some basic limitations and difficulties inpsychotherapy and in treatment in general.One such limitation in therapy is, especially at the

beginning of the treatment process, is the patient’slack of insight into their own illness. The bodyfunctions metaphorically, but this symbolic com-munication via the body is not experienced asmetaphors by the anorectic patients, but rather asconcrete reality. Concretisation in this sense struc-tures experience by making it thing-like in itsnature. Once the ineffable and intangible aspectsof experience, like feelings, moods, tensionstates, sensations, impressions, ideas, abstractions,relationships, attitudes and so on, are reified, theycan be controlled, manipulated and managed asthough they were objects in the material world.Objects, and in the case of anorexia nervosa theobjectivated body, are experienced as real in havingdefinite form, solidity, substance, weight, texture,taste, smell and temperature. In contrast, thenon-objective aspects of experience like emotionsand thoughts are fleeting and ephemeral, no morepalpable than the air we breathe, yet equally vital toone’s experience. Irrespective of the aetiology, thisde-symbolisation represents a defect in the verymode of experiencing, and thus a lack of psycho-logical self-insight into the anorexic behaviour aspathological behaviour.Another probable limitation in therapeutic pro-

cesses is the fact that many persons with anorexianervosa have an experience of receiving somethingpositive from their condition. It may be anexperience of being beautiful, of being unique, ofhaving a feeling of control, a feeling of predictabilityand clarity and/or that the illness representscomfort and protection (Serpell, Treasure, Teasdale,& Sullvian, 1999; Skarderud, 2000). Bodily qualitiesand experiences are felt as actual solutions here-and-now for emotional, cognitive and relationalproblems. On this basis, anorexia can be understoodas an expression of a psychological defect or flaw,and symptomatic behaviour as attempted solutions.The symptoms can basically be regarded as ‘a


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selfing device’ to promote self-development and asense of self-control through body rituals (Baerveldt& Voestermans, 1998). This demonstrates thefundamentally paradoxical nature of anorexia:One seeks a rescue which destroys one’s life. Inclinical reality such phenomena are experiencedand described as a lacking and/or unstablemotivation for change.A third possible contribution to weak therapeutic

alliances does not concern the patients, but thetherapists; and our problems with being able tounderstand the very nature of these disorders. Alack of understanding can lead to a lack ofcommitment and patience; or worse—to aggressionand rejection. And the concrete way of functioningmentallymay represent paucity or absence of verbalaccompaniment, often contributing to frustratingand non-productive silences in the therapeuticsituation. Filled with such frustrations, therapistsmay elicit potentially treatment-destructive inter-ventions. Here again, concretised metaphors aresuggested as a descriptive tool for promoting anunderstanding of the central traits in anorexianervosa, and thus realising that this has con-sequences for therapeutic work.Hence, promoting understanding of psychopatho-

logical features as well as obstacles in therapeuticencounters, the presented concepts are adequate forguiding therapists into better directions in their workwith this group of patients.

CONCLUSION

In terms of being a symbolic tool, the body can bedescribed as rich. The metaphorical body canconvey a number of different messages. However,anorexia nervosa demonstrates the shortcomings ofbody language, given its impossibility to commentitself. There is a need to develop a language aboutsuch forms of communication—a metalanguage.This paper discusses with concretised metaphorsand psychic equivalence as useful conceptual tools,including both phenomenological descriptions andclinical-practical consequences.In clinical practice, psychotherapy is an ambition

to create a working relation to co-develop such ametalanguage. Psychotherapy with individualswhose early experiences have led to a compromisedreflective function should be focused on helpingthem to build this interpersonal interpretivecapacity. One way of conceptualising the psy-chotherapeutic enterprise may be as an activity that


is specifically focused on the rehabilitation of thisfunction.The translation of symptoms or enactment into

‘the universe of things said’ and symbolised vialanguage frees it of its self-destructive impulsivequality and leads to understanding and self-control.The undoing of a symptom is in part the creation oflinguistic metaphors from symptoms. In thiscontext, psychotherapy in anorexia nervosa canbe described as a relational process where con-cretised metaphors might develop into genuinelinguistic ones, gaining the function of an ordinary,mediating and metaphoric expression (Searles,1962; Shaly, 1987). The aim is to create a reflexivespace, with the possibility of distinguishingcontrol from control, emotional clarity frompurgingand attempted self-repair and self-constructionfrom self-destruction. Psychotherapy, as ‘metaphor-analysis’ (Carveth, 1984), is an exercise in becomingconscious and self-critical in our employment of themetaphors we live—and eat—by.

ACKNOWLEDGEMENTS

The author wants to thank Sonja Heyerdahl andSteinar Kvale whose contributions have been ofvital importance for the realisation of this paper.And a great thank to the patients who have beenbrave to share difficult aspects of their lives. Theresearch work has been financially supported byResearch Council of Norway.

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