Bulimia: A False Self Identity 

Clinical Social Work Journal 13, 4:305-315, 1985.  

ABSTRACT:  

 This article is based on the author's clinical  experiernce with fifteen bulimic women over the past five years. It covers the family origins, unique chara cteristics, internal dynamics, and treatment of bulimia.  Bulimics have a cohesive, albeit pathological, identity based on the False Self. Relying on D.W. Winnicott's theory of ego splitting between the True Self and False Self, the author elaborates the components of False Self identity. This  author concludes with a comparison of the effects of group and individual therapy, and suggests that group is generally more effective than individual but that a combination of the two  is optimal. 

Bulimia is attracting growing clinical attention for several reasons.

I became interested in bulimia in response to clinical work with fifteenbulimic women over the past five years. I have seen these women inindividual treatment and/or in a therapy group limited to women with this disorder. (The group has been in progress for nearly two years.) In addition to clinical work, I have interviewed five mothers and two fathers of bulimics.

That the members of my sample are all female reflects the gender based nature of this disorder. Investigators estimate that 90 percent or more of bulimics are female (Bruch, 1979; Ruffino, N.D.). Most writers on the subject attribute the gender basis to the inordinately strong cultural emphasis on female slenderness.(2). 

Like anorexics, these women usually come from white, middle-class families that are structurally intact. Most of the women are in their  twenties and thirties (the age range is twenty-three to forty-two). Over one-half of the women are unmarried and childless. Typically, they are shapely, physically attractive, and feminine in dress and manner. They appear calm, poised, well-mannered, and modest about their achievements, despite the fact that the majority are quite accomplished. Most of  the women are college educated and hold responsible professional positions--as attorneys, teachers, accountants, engineers, and administrators.

The literature contains considerable discussion about the appropriate in other disorders, such as anorexia nervosa, obesity, and schizophrenia(Johnson& Sinnott, 1981; Levitan, 1981; Loro& Orleans, 1981; Hsu,  Mettzer & Crisp, 1981). 

While the women show considerable variation in the severity of their disorder, their symptoms are similar. All the women obsess about food and weight, engage in binge eating, and the majority purge  by vomiting or using diuretics and laxatives.  The women exhibit relatively uniform conformity to the characteristics of bulimia describwed in DSM III(American Psychiatric Association , 1980:69-71).(3)

The women also show a striking similarity in identity formation, characterized by an overdeveloped False Self. This form of identity may also appear to varying degrees and with varying frequency in other disorders, but it is an invariant, and, I believe, a defining feature of bulimia.  Therefore, I shall focus this paper on the genesis and components of the False Self identity as well as on the internal mechanisms and symptoms by which bulimics maintain it.

Donald Winnicott's (1965) theory of ego splitting between the True Self and False Self captures the essence of identity formation that I observed in bulimic women. Winnicott defined the True Self as that part of  the infant's psyche that feels internal and spontaneous and that generates feelings of being alive and real. The False Self is an exaggerated outgrowth of that part ofthe self that is turned outward toward the world. In an overdeveloped False Self, the public face, the polite social attitude that all people adopt at times becomes the internalized sense of self, covering over and masking the True Self. This submergence of the True Self gives rise to feelings of emptiness, futility, and unreality.

Winnicott suggested that the split between the True Self and False Self begins in infancy and results from the primary caretaker's, usually the mother's, failure to respond appropriately to the infant's gestures and cues. Hilda Bruch (1973) identified the same characteristic in families with eating-disordered children. I can only speculate about the infancy of my bulimic clients, but judging from later memories which probably telescope analogous earlier experiences, a similar pattern appears in their family recollections.

The bulimic woman is usually the first-born child in her family. Both parents appear to have been excessively dependent on her for their own security and self esteen  The bulimic daughters experienced an extreme  form of role reversal in which they were valued for their ability to mother their mothers and take care of their fathers' self-esteem. Both parents  posed exceedingly high demands on these daughters. They expected them  to be model children-happy, accomplished, self-sufficient, independent,  and compliant. And they showed a consistently low tolerance for daughters' expressions and behavior that failed to fit this model. As a result, parents obstructed their  daughters' True Self development. Other investigators of families with eating-disordered children identify similar characteristics (Bruch, 1979; Minuchin, Rosman & Baker, 1978; Sights & Richards, 1984).

Such family dynamics are common in the histories of many clients who don't develop eating disorders.  What is unique in the bulimics' family experience to produce their binge-purge symptoms?  The parent's inordinate emphasis on food and physical appearance suggests a partial explanation.  As Bruch(1973) noted, mothers in families with eating-disorderd children become  oerinvolved in their daughter's nutritional functionlong past the age when it is appropriate.  A twenty-three-year old bulimic squirmed when telling about the enormous lunches her mother packed day after day.  "When I was just in the third grade, she'd pack a sack with three sandwiches, carrots, an apple, orange, banana, cookies. I told her it was too much. She seemed so upset, so hurt. I think I cried. After that I just three my lunches away and never told her."  Other bulimics rcounted similar experiencwes in whichmothers treated food as a cure-all.  This concept fell on fertile ears in daughters who were denied other avenues for expressing their inner needs. The daughters came to believe that food would ease all discomfort and reward all pleasure. Typically they thought of food as their best friend.

But they also considered it their worst enemy because usually both  parents placed an exaggerated emphasis on external appearance. While it's true that the culture is phobic about female weight gain, the families of these women appear to have been even more extreme. For example, a bulimic woman painfully recalled her father calling her mother "lard  ass" when the mother outgrew a size 6 pants suit. Another recounted having been taken to a doctor for a preventive diet at the age of thirteen even though her weight was normal. Others remember having been taken to charm schools at a similar age.

When parents are overinvolved in their daughters' eating  behavior and at the same time close off  other channels for expressing inner needs, then ineluctibly they  condition daughters to confine the expression of True Self needs to the areas of food and eating.

If at the same time parents are overinvolved in their daughters' body size, they foster a schism in daughters who come to view food not only as their best friend but also as their worst enemy.  A forty-two-year-old bulimic woman lamented this schism: "I seem to spend my energy either thinking about what I'm going to eat or about what I am not going to eat. I'm either on one track or the other. That's what makes me feel so tired out."

Returning now to the issue of parents squelching daughters' True Self development, it is important to identify the central areas of suppressed development.  These are namely  two: dependency needs and the need for autonomy.  Parents failed to acknowledge the bulimic daughters' need for comfort, nurturance and gentle guijdance or for an independent identity, although they expected the daughter to have the outward appearance of independence.

The bulimic women came to see both sets of needs as enormously threatening  because parents responded to them with some form of emotional abandonment and rejection.  Daughters' assertoin of autonomy needs was frequently met by verbal or physical abuse b one or both parents. Expression of dependency needs could also provoke abuse, for instance, two women learned that their fathers had beaten them for crying before they were six months old.

But more compelling is the women'smemories of parents'covert rejection of both dependency and autonomy needs. Emotional abandonment by parents took the form of making the daughters feel as if they didn't exist.  Madelaine twisted in agony when describing this feeling to the group. "Right in the middle of a word, it didn't matter what kind  of feeling I was talking about, she'd walk right out of the room, just like that. Anything would have been better than treating me like a grain of sand. Oh,  Idon't want to talk  about it anymore, I can't."

Bulimic daughters also felt emotionally  bereft  by parents' unpredictable and erratic respoonses, responses the women refer to as the "shifting ground" approach.  Such responses made the daughters feel as if they were crazy.  Thirty-year old Mary's recent intraction with her parents provides a dramatic example. Living in a different state, Mary's parents constantly  pressured her to visit. Mary always complied until after she started therapy. Then she decided to asset her interests and canceled a scheduled  visit. Drawing a deep breath Mary emphatically informed her parents of the change in plan.  She was stunned by her parents' supportive response. Mary started the next group session with these words. "I think I'm crazy.  I think I've beenh wrong about my parents all my life. they really are supportive and understanding. What's the matter with me that I haven't seen it?"  Another member who had received therapy for nearly a decade interrupted Mary: "No, you're not crazy. They are. they just shifted ground on you. That was my parents' favorite ploy and it drove me crazy too before I understood  it."  This conversation sparked similar memories in other group members. When the women became strong enough to assert some inner direction, parents shifted ground in an apparent effort to demonstrate that there was no need for assertion or defiance. They stripped their daughters of the raison d'etre for True Self expression. 

With this perception of danger, starting in infancy and reinforced through the years, the women increasingly concealed their True Self, not only from parents but from themselves, for it's frightening to acknowledge tghe existence of feelings that evoke consistent disapproval and invalidation.  Nor did they have access to a substitute envitronment that might have afforded corrective experiences.  Their families were generally socially isolated and highly enmeshed.  Parents centered their social lives  within the family and expected daughters to do likewise.  They actively discouraged contacts outside the family and especially condemned confidences about family matters to non-family members.

As a result of this social isolation and the dangers of True Self expression in their families, the  bulimic daughters increasingly focused on developing a False Self, one that wouldmask the parts of the True Self they considered most dangerous--dependency and autonomy needs, and prevent the dreaded abandonment by parents.  Winnicott did not develop the concept of the False Self beyond defining it and considering its origins.  I  extend the concept by identifying its componenents as they appeared in the bulimic women I know.

The False Self develops in part as a response to pafre;nts' demands for super performance.  The bulimic daughters responded to parents' expectations that they be competent, responsible, little adults with a pseudo-adult  identity.  As fafr  back as they remember, bulimics felt  burdened by demands for super performance in whatever they did.  They lack  memories of a carefree, playful, childlike time in their early  lives.  "I don't remembefr friends and fun," recalled a twenty-eight year old bulimic.  "I cold never be idle at home.  I could never sit down for a minute without my mother or grandmother yelling at me  to get up  and so something useful,"  another bullimic recounted.  the idea of  behaving in a spontaneous or carefree manner was alien to these women.  When Children must  bury their child selves and  behave like miniature adults, the most they can achieve is a pseudo-adulthood.

Embedded in the pseudo-adult identity is one of pseudo-independence which e volves in response to parents' contradictory demands. As mentioned earlier, parents expected these daughters to be both compliant and independent. Clearly one can't be both on a consistent  basis. Finding ways to manage such contradictory demands posed a difficult developmental task for bulimics. They adapted by developing apseudo-independence that did not thrreaten teir conformist stance. Indeed,  compliance was a striking characteristic of  bulimics in early therapy encounters.  They extended every effort to discern and meet myh expecations as well as tose of others in teir social or bit.  A thirty-eight-year-old  bulimic gave compelling expression to this overcompliance: "I feel centered in  other people's expectations.  I concentrate on second guessing them to know what they want. I don't know how to be centered in myself. It's an alien idea." This same woman described repeated parental pressures to be or to appear to be independent. Pseudo-independence creates intense tension, for its maintenance requhjires obsessive concern with outward signs, with the appearance of self-sufficiency and self-direction no matter how tremulous the women feel on the inside.

Another central component of the False Self idenenty is pseuco-achievement. Whilepafrents of  bulimics emphasized achievement and accomplishment, they failed to promote the kidns of experiences that provide the skills and attitudes necessary for mastery and for enjoying adult work roles. Adult accomplishments grow out of prior experiences in exploration and experimentation. When pafrentsencourage and affirm such activities, the child incorporates attitude and habits that facilitate andmotivatgecontinued exploration and mastery. These bulimic daughters wereexpected to achieve without this preparatory socialization. Risk aking and exploraltion appear to have been singularly absent from their repertoire of experience.  Parents usually kept them close to him/ They discouraged spontaneity and playfulness, activities in which risk taking and exploration naturally occur.  The buylimic women were trained to achieve the product--the A's in school, the promotions at work.  TGhey were expected to demonstrate the outward signs of achievement in the asence of its inernal dimension--the inner motivation and gratification that usually accomply it.  As a result, the women lack attachment to and gratification in their careers.Susan, a thirty-four-year-old  economist cogently described this lack of attachment.

     Why can't I commitmyself to my job, to my career?  Why can't  I  fell strongly about it one way or the other?  I do the job for money. That's what a job is for. I don't gbet  inner pleasure...Butno one thinks that about me. In my heart of hearts Iknow there's something crazy about this.  I appear to b doing well. I'm smart enough to carry it off. but I don't get anything internal from it.

This lack of attachment in the presence of considerable mastery is the essential ingredient of pseudo-achievement.

Mainaining a False Self identity places bulimic  women under chronic and intense stress, from performance prressures and from having to consistently act as an independnt, self-contained, self-satisfied adult no matter how frightened and uncertain they feel on the inside.  The obsession with food and weight is one of the ways they try to cope with these pressures. They binge for relief from False Self pressure and they purge to reafffirm allegiance to their Fale Self identity.  I shall say more about the functions of the bulimic symptoms later.

The women experience tension not ony from False Self pressures but between True Self and False Self demands.  While the False Self is their central identity, the True Self does  not lie passive anddormant. The women'sinner needs and desires clamor for expression and threaten the very foundation of the False Self. this threat, of corse, is closely linked to the fear of abandonment from which they think the False Self protects them.  Thus they struggle to keep True Self desires  muted.

One of their chief means is to whip these desires into silence with self hatred. Harry Guntrip" (1969) concent of an  anti-libidinal ego that hates and persecutes True Self, or in his terms. libidinal desires, strikes to the heart of this process.(4)  The aniti-libidinal ego's frelentlessattacks on the TRue Self functions to promote and maintain a False Self identity.

Whilelon one level bulimic women fear True Self expression and try to mute it, on another they regret the loss of this vital part of themselves.  They exist in a state of chronic vacillation between wanting and fearing those desires that lie deep within them.

This vacillation carries over to bulimics' relationships. their True Self desirs attract them to close relationships. And their fear of the libidinal desires awakened in relationships  triggers abandonment anxiety, which in turn brings their anti-libidinal ego into immediateplay.  Aforty-year-old bulimic gave poignant expression to this tension.  "When I'm in love  I become crazy.  I want him to take care of me.  I become like a disgusting baby.  I turn into mush.  I hate myself when I become mush.  It's better to be alone. I want to find a way to be happy without a lover."

The tension between desire for and fear of relationships leads the women to adopt a half in-half out position(Judith Wallach and Eugene Lowenkopf's 1984 study of bulimic women, based on a battery of psychological estgs, identified asimilar tendency to withdraw from relationships.)  the  women express this vacillation in varoius ways--by frequent chages of partners or by  splitting  off part of themselves in relationships, for example, the sexual part, or by confining intensity to casual relationships while they avoid relationshiops in which such intensity would be appropriate.

I believe the bulimic women's  symptoms represent an effort, however futile,  to find a way ouf of the dellemasposedby chronic tension between True Self and False Self desires, between yearning for and terror of close relationships.  To relieve the pressure, they give their True Self periodic airings in tghe form of food binges. This is one of the few conscious libidinal indulgences the women  allow themselves.  In this sense the binge is a symbolic and disguised expression of the urge to be emotionally fed.  In another sense however, the binge often represents and effort to accomplish the opposite--to mute True Self desires that threaten to burst into awareness by stuffing them away with food.  The mixed funcitons of the binge leave the women feeling  conflicted and anxious after the binge is over.  they try to relieve the anxiety by undoing the binge through a purge.  Then the pressures for expressing and muting the True Self are temporarily stilled.  Itg is a tenacious symptom, I believe, because it represents one of the chief means by which these women maintain their sanity.

Similar to other clinicians, I find bulimics difficult to treat(Russell, 1979; Fairburn, 1980).  these difficulties arise from several features of their disorder.  One  is their inordinate fear of the emergence of True Self desires, particularly dependency hinger and autonomy, lest it lead to abandonment by the therapist. The second i their overdeveloped False Self which the therapist can't ignore since it's the heart of their identity and which the therapist can't support becauseit's the heart of their disorder. A third, also stemming from their False Self,isperforma nce anxiety which, when itbecomes intense, may lead to fligyht from treatment.

The False Self identity gives rise to very contradictory goals in therapy.  The bulimic women want inner peace but not at the cost of activating their inner needs. and they want to feel authentic but not at the cost of undermining their False Self identity.

These  contradictory goals created a dilemma for me.  If I resopnded to the women's  wish to strengthen their False Sel, then I colluded in their pathology.  When I first started treating bullimic women I was often tempted to err in this direction because I found the women's amicability,compliance, and cooperativeness very seductive. I was jolted injto awareness of the pitfalls of such complicity when one of the  bulimic women expressed anxiety lest I get hooked into playing her games, at which she knew she was the expert. "I know how to relate to people about the things that don't matter and how tokeep tghem away from those that do.   My strongest anxiety was that you would play those games with me."  Indeed, had I, this woman would ahve undoubtedly become disillusioned with therapy, for I would have set up a repeat performance of the family dynamics that crippled her in the first place.

However, avoiding this kind of collusion meant focusing on the hidden part of the women's identity, particularly on their suppressed dependency and autonomy need. Such a focus often provoked intense anxiety in the women,l which, in turn, aroused my own abandonment fears, for I seensed he frgilityof this part of their identity and the danger that they might flee therapy to avoid its emergence.  My experience with a thirty-seven-year-old bulimic, Anne, an adeministrator, is illustrative.  Geographical fllight was one of Anne's major defenses against attachment to people and work and against the inner empti ness she felt because of the lack of attachment. when either threatened to come to the surace she moved to a new state and felt renewed in the process of adapting to a new physical and job environment.  She repeated this process every few years throughout her adult life. After two and one-half months of individual therapy, anne proposed resigning from her job and traveling to Europe for an  indefinite period of time. I interpreted theunderlyhingmeaning of her flight. At the same time I feared that such an inerpretation would intensify her anxiety about therapy and reinforce her decision to flee. I took the risk. Of course timing is always a factor in the effectiveness of interpretation but I belive taking that risk enabled Anne to take one of her own by remaining in therapy. This andsimilar experiences convinced me of tghe critical importance of being aware of my abandonment anxiety in the early period of therapy.

 But it was equally imporant to recognize the reality that bulimic women often do flee from treatment, whatever the therapist does or doesn't do.  Typically, the women have a longhistory of sampling different therapies and therapists.  This is consistent with their vacillating pattern in relationships.  Ten of the fifteen women in my sample  have a  history of prior therapy; most had changed therapists several times, some over a period of ten years and longer. Probably these prior experiences paved the way for a fuller therapeutic commitment at a later time.  Given their intense fear of close relationships and the True Self desires they generate, the women may have to approach therap with small, tentative steps until they are able to tolerate more.

TGhat  is one consideration in the treatment of bulimia, but I think another is equally  important, that is, whether individual therapy is the treatment of choice.  the majority of my bulimic clients were better able to tolerate group  than individual treatment. Other clinicians have come to the same conclusion (Stevens & Salisbury, 198r4;Boskind-Lohdal-Shite, 1978; Byrne, Benner & Yager, 1984). I donotmean a group composedofpersons with mixed problems bt one limited to bulimics. Then bulimics start therapy, often they are too frightened by spontaneous expression, especially anger, to remain in a group in which such expression occurs.  In a bulimia group, because of the preponderance of false Self qualities in the early stages, the women experience a protected environment, one which is relatively free of engative expressioins and is highly supportive and sympathetic.

The bulimia gropup contains and reduces some of the very fears that make the women feel  overwhelmed and inclined to flee indiidiaul therapy.  It protects them from premature exposure of True Self desires, especially dependency wishes. Bulimics experience this danger far more inensively in individual therapy where they are consistently on the receiving end of nurturance and support than in agroup where interaction is reciprocal.  This was poignantly illustatrated during a recent grop meeting in which we explored why Jean, who participated in both individual and group therapy, gave a party for the group from which I was excluded.  "  I didn't think of this when we talked about it before but maybe I switched my dependency from you to the group.  I remember thinking I  couldn't need you and I neededpeople and then I was thinking it felt saferbonding with the grop.  I think that may be why I deidn't think to invite you to the party."

The dependency issue, of course, arisesin both settings but the women experience it as far less threatening and overwhelming and therefore as more manageablwe in group than individual therapy.

The group also protects women from some of the pressures involved in maintaining the False Self, that is, from performance anxiety.  Bulimics tend to project onto the therapist the same perfomrance demands they experienced in their families; they feeel compelled to  meet these assumed expectations; and they end  up feeling hugely  overburdened. This exerts an additional pressure for leaving individual treatment. In the group, women may work or not work, talkor not talk, take or gi ve, and in any case they receive benefit and feel accepted.  The bulimic women frequently attest to the relief from performance pressure they experience in the group.

While the group helps to contain some of the fears that tend to overwhelm women in individual therapy,it also serves the opposite funcion, of highlighting certain fears that are less accessible for exploration in individual therapy.  The most important of these is abandonment anxiety.  Any expression of difference, nhowever slight, arouses abandonment fears. Examples are legion.  Mothers and married women whoare in a minority  in the gropu fear expressing their concerns lest nonmothers and unmarried women reject them.  New  members fear oldermembers will reject them for holding back their progress. Members who think their progress is slower than others believe the rest want them toleave the group. Concomitantly, those who have made the most rapid progress are convinced the slow movers want them to withdraw.  One member, for example, withheld information about the cessation of her bingeingfor months for fear those who still binged would want her to leave the group.  Such differences arebrought out far more in a group setting where members' self-disclosure is high than in individual treatment where therapist disclosure is low.

An additional  benefit to groujp versus individual therapy stems from its provision of a collective ego which facilitates facing issus the womem fear probing by themselves.  In the process,  theyh strengthen weakly developed part s of their identity.  They come to a collective recognitoin of their yearning for True Self expression and of contempt for the False Self inauthenticity.   Because the women are all in tghe same boat and arrive atr this awareness together, they are able, some for the first time, to form open and genuine bond.  As their bonding capacity increases and their abandonment fears diminish, they devote increasing energy to building an autonomous sense of self.

Usually group therapy is a supplement to individual treatment. The reverse patter often occurs in my clinical experience with buliics.  Freqquently they strt individual treatment after gropu therapyis well underway, when their fears of a more intense therapeutic relationshp have diminished.  The combination of gropu and individual therapy appearsto be optimal in the treatment of bulimic clients.  Mintz(1982 came to a similar conclusion.

In sum, bulimics, indeed, are difficult to treat. Yet, the very conditions that make this so, tyhe deep-rooted e entrenched nature of their problems, tghe perpetual warfare between their True Self desires and False Self mandates, the dilemmas they face in their yearning for and fear of relationships, the compromise solutoins that keep them sane but in agony, also furnish strong motivation for recovery.

 NOTES

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Bruch, H. (1979). The golden cage: The enigma of anorexia nervosa. New York: Basic Books.

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Fairburn, C.G. (1980). Self-induced vomiting. Journal of psychosomatic Research. 24, 193-197.

Guntrip, H. (1969). Schizoid phenomena, object-relations, and the self. New York: Internatkional Universities Press.

Hsu, L.K.G., Meltzer, E.S., Crisp, A.H. 1981) Schizophrenia and anorexia  nervosa.  Journal of Nervous and Mental Disease, 169, 273-276.

Johnson, R.E., &Sinnott, S.K. (181.  Bulimia. American Family Physician. 1981. 24, 141-143.

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Loro, A.D. Jr., &Orleans, C.S,. (q1981.  Binge eating in obesity: Prelininary findings and guidelines for behavioral analysis and treatment. Addictive Behavior. 6, 155-166.

Mintz, N.E. (1981) Bulimia: A newpefrspective. Clinical Social Work Journal. 10, 289-302.

Minuchin,S. Rosman, B.L.   Baker, L. (1978) Psychosomatic families:Anorexia nervosa in context.  Cambridge: Harvafrd University Press.

Ruffino, R.W. (N.D.)  Bulimarexia: The lawful addiction.  Unpublished.

Russell, G. (1979). Bulimia nervosa: An  ominous variant of anorexia nervosa.  Psychological Medicine. 9, 429-448.

Sights, J.R. &Richards, H.C. (1984).  Parents of  bulimic women. The International Journal of Eating Disorders, 3, 3-13.

Stevens, E.V. &Salisbury, UJ.D. (1984). Group therapy for bulimic adults. American Journal of Orthopsychiatry. 54: 156-161.

Wallach, J.D. & Lowenkipf, E.L. (1984). Five bulimic women: MMPI, rorschach, and TAT characteristics.  TheInternational Journal of Eating Disorders. 3: 53-66.

Winnicott, D.D. (1965).  The maturational processes and the facilitating environment: Studis in the theory of emotional development. NewYork: International Universities Press.