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Journal of Child Psychotherapy

Vol. 35, No. 1, April 2009, 6280

Complications in the development of a female sexual identity

Jeanne Magagnaa* and Tara Pepper Goldsmithb

Flat 5, 33 Eton Ave, London, NW3 3EL, UK; b14 Rugby Street,
Flat 3, London, WC1N3QZ, UK

This paper describes the struggle to develop a female sexual identity and the
importance of the roles of the father and mother in this struggle. The clinical
illustration is taken from the psychotherapy of an anorectic adolescent.
Keywords: female sexual identity; role of the father; anorectic; introjective
identication; adolescent development

An anorectic girls development of her female sexual identity and the inuential role
of the father will be presented in this article. Clinical illustrations will derive from
twice-weekly psychoanalytic psychotherapy with a 17-year-old anorectic Italian girl,
As I look around at eight anorectic girls in a group therapy session, I ask myself:
What common problems in developing a psychologically healthy female sexual
identity do these young women have? They are high-functioning in their academic
work, while at the same time they remain little girls in their emotional lives. They
do not seem to view their emotions with compassionate comprehension providing
reective understanding. I am struck by how, as the group begins, they dont
remember intensely emotional events from the group meeting held only one week
previously. They all agree that not remembering is one of the key ways they cope
with dicult moments, those dicult moments in which conict, aggression or
psychic pain has been revealed. They often say, I just dont want to talk about it,
when referring to some very hurtful event. Turning to anorectic self-harm that is,
starvation or cutting seems preferable to crying or feeling sad, hurt or angry. More
than one patient has said, I would rather cut than cry . . . crying is too painful!
Without exception, the girls nd it dicult to dierentiate what would be rude
to say to a person and what would be rightfully expressing a dissenting point of view.
To be a strong, assertive young woman seems a challenge; being a submissive young
woman feels safe.
Although all eight girls share these common problems, they dress very dierently.
They might wear the clothes of little girls or the permanently present tracksuits of
latency-age boys or style their hair in pig-tails. Others have sexually developing
bodies, use make-up, wear pop star trendy clothing of tight low-cut jeans and short

*Corresponding author. Email:

ISSN 0075-417X print/ISSN 1469-9370 online
2009 Association of Child Psychotherapists
DOI: 10.1080/00754170902750164

Journal of Child Psychotherapy


t-shirts, and have pierced ears, tongues, noses or belly-buttons. At the beginning of
the group, each girl rmly asserts that if she loses the identity of having anorexia
nervosa her emotional needs will not be met by her teachers, nurses, psychotherapist
and parents. More specically, there is a certainty that the adults will not recognise
that the academically able adolescent girl is not psychologically ready to be
It is probably true to say that most girls have anxieties about becoming sexually
mature, but each of these anorectic girls is particularly anxious about losing her rm,
straight, latency-age body. Breasts and curved hips are invariably associated with
being fat. They are also perhaps unconsciously associated with being sexually
mature/active; perhaps with being pregnant, for there is a feeling that you get fat
when you are pregnant; this fear is in addition to the cultural taboos against being
fat. Menstruation represents something messy, dirty, the body out of control.
Control is felt to be needed and normal bodily rhythms seem out of each girls
control. There is a huge anxiety that the development of increased sexual impulses
and the ability to bear children can lead to the risk of encounter with persecutory
internal objects. Boys are ne as long as they are just friends, but confusion reigns if
a girl has a sexually and/or emotionally intimate relationship with a boy.
Several of the girls have had adverse experiences which contributed to a devalued
sexual identity. One third of these girls have had sexually abusive experiences
(Palmer et al., 1990). In addition, family therapy sessions have often revealed serious
parental quarrelling, clinical depression in the parents, parental eating disorders,
parental addiction to alcohol or drugs, and emotional and/or physical abuse of the
young people. I am struck by the number of girls born from unplanned
pregnancies. These family dynamics are symptomatic of a more basic issue: both
the parents and their daughters have diculties in compassionately comprehending
the girls inner emotional lives. In lieu of compassionate comprehension of emotional
experiences, there is an early infantile development of primitive omnipotence (Briggs,
2002). Primitive omnipotence involves avoiding the frustrations of dependence on
the parents. Primitive omnipotence also prevents impingements of others by using
the self as the source of satisfaction. Omnipotence is aptly described in Paul Simons
lyrics: Ive built walls that none may penetrate . . . I have my books, and my poetry,
to protect me. I am shielded in my armour. For various reasons, explained more
fully below, each girl feels she must control rather than depend on the parental
couple. Simultaneously, each girl experiences limited depressive concern for the
parental couple; this concern would permit the internal parental couple to exist as a
sexual, nurturing pair who have other children besides herself. While these dynamics
are common to all the eight girls suering from severe weight loss and anorexia
nervosa, each girl has a unique personality, a particular family narrative, dierent
responses within herself and dierent interactions with signicant others.
Drawings by anorectic girls, some of which are shown in my chapter on
individual psychotherapy in Anorexia Nervosa in Children (Magagna, 2000) often
reveal a progression of development:

The experience of the self as a very fat and ugly person

The skinny, starved self caged in by omnipotent control
The self emerging with persecutory anxieties, fears of attack and rape
The wish to be in the middle of the parental couple, splitting them up, rather
than maintaining the generational boundary between parent and child


J. Magagna and T.P. Goldsmith

(5) Possessive jealousy of primary caregivers relationships with siblings
(6) More integration of split-o parts of the self
(7) Development of a healthy female identity comprised of identication with
good parental gures. This more spontaneous drawing of the normal
adolescent female body suggests a spontaneous interplay between ones
bodily sensations and feelings and a compassionately comprehending self.

Although underneath uniquely dierent from all other anorectic girls, what each
anorectic young girl shares with other anorectic girls is the reality that she is not
psychologically ready to grow up and bear anxieties aroused by sexual development,
even slight encounters with sexual intimacy and the responsibilities of growing up.
Psychoanalytic psychotherapy with an anorectic girl
The question posed is, Will twice-weekly psychoanalytic psychotherapy be sucient
to assist a very emotionally deprived and sexually abused anorectic adolescent girl
develop a healthy female sexual identity? Can psychoanalytic psychotherapy provide
sucient compassionate comprehension to give meaning to this girls emotions and
enable her to develop and internalise a good parental couple the base of a healthy
female sexual identity? Compassionate comprehension refers to the capacity of the
psychotherapist unconsciously in be touch with the girls evacuations or communications of pain, her expressions of pleasure, to receive them, to be able to engage
with and savour them if calm and loving, or to modulate them if distressed and
hating, and to thoughtfully hand them back to her in recognisable and now tolerable
form (Waddell, 1998: 31).
Brief history
Grazia is a 17-year-old brown-eyed Italian girl, with an abundance of curly shoulderlength chestnut hair. Her parents emigrated to the UK from Italy when Grazia was
eight years old and her two brothers, Marco and Luca, were six and four,
respectively. From hints the parents gave, I wondered whether Grazias alcoholic
father, a car mechanic, was eeing from some nancial and legal problems
encountered in Italy.
When Grazia was 10 years old, the father suddenly disappeared from the family
without giving his whereabouts or re-contacting the family who were left without
any money. The children were ashamed that they were without a father and, despite
the fact they were very short of money, for many months they hid the fathers
mysterious departure from everyone. Later it was discovered that the father was
living with another woman and wanted absolutely no contact with Grazia, her two
brothers and her mother. Grazias traumatised and depressed mother did not pursue
him to give any money to the family so they were nancially bereft.
Phase One: The psychotherapy assessment
Grazia, severely emaciated and suering from anorexia nervosa was accompanied to
her rst hospital appointment by her 37-year-old mother. Her confused, uncertain
mother seemed like Grazias daughter, for the mother appeared completely under
Grazias control. Prior to Grazias birth, the mother had experienced severe clinical

Journal of Child Psychotherapy


depression for which she received medication but no psychotherapeutic assistance.

Grazia denied any need for nurturance while maintaining a stick-like, severely
emaciated 10-year-old latency-age shape.
I experienced Grazia as physically 10, but psychologically going on 25. For seven
years she had been paying the bills, getting take-away meals and cleaning the at.
For many years, Grazia had decided what she did with her time, with whom she
associated and when she went out. When Grazia was 11, her mother took a full-time
cleaning job. Her two younger brothers jokingly referred to Grazia as the little
dictator because she had taken the role of a bossy dad in relation to everyone in
the family. Grazia trusted only her own common sense and felt she could not rely on
her mother. Grazias mother also felt grateful that her bright young daughter could
and did take on the leadership role in the family when the father left home.
Mothers depression, alcoholism and anxiety over being abandoned may have
blinded her to the emotional dangers to Grazia in taking on this parentied role.
Grazias sturdy, omnipotent, bossy dad identication felt a developmental necessity
for Grazia to survive the anxieties of lacking parents both externally and internally
to nurture and support her. However, her bossy dad omnipotent identication now
prevented her from acknowledging and developing the more vulnerable, dependent,
feminine parts of herself.

Phase Two: Acknowledging the body/self sensations of fat and the presence of
omnipotent control
If we are to help patients with their hidden heartbreak, we have to make acquaintance
with the despairing part of ourselves.
(Tustin, 1986)

Initially, Grazia was a little dictator not only in her family, but also in relation to
the doctors, whose attempts to weigh her were continually fought. She weighed 75%
weight/height and although only 34 kg she wanted to lose a couple of stones.
Grazia said that she felt sick, bloated and fat if she ate. At 15, she had stopped
menstruating because of her low weight. In the initial assessment, Grazia stated that
she was terried by three things; food, the doctor with the scales who had a duty to
weigh her and missing school. She added, I want to be 34 kg and have A stars.
Nothing else has any meaning. Grazia went on to say, I dont want to get better.
I am not a therapy person, not a meal person, not a drinking person.
In the assessment, Grazia rmly asserted that she wanted to be slim, she was a
perfectionist, she had a lot of friends, she always liked to please people. I took note
of her response to my question about what adverse experiences she considered
herself to have had had in her life. She said, I havent been abused by my uncles or
any family members. I said that leaves some other possibilities, but she said, No.
I oered two sessions of psychotherapy per week and mother attended family
therapy alone because the father and the two sons refused to join her.
During the rst nine months, Grazia dominated the sessions with talk about
food/dieting talk, exam anxiety and conversations about her two brothers laziness. I
discovered that she had slept with her parents until she was ve years old and that
currently she, her two brothers and her mother still shared the same bedroom.
Grazia said, Ive taken over dads role. I look after my mother.


J. Magagna and T.P. Goldsmith

During one year of psychotherapy, Georgia gained 8 kg and began menstruating.

It was then, when the contraceptive eects of anorexia nervosa were not working,
that the sexual problems became more obvious.
Grazia began crying in the sessions. She complained about feeling numb. She
started describing large boys, violent gangs, a sense of high crime in her
neighbourhood, the lack of safety, how she ran when she saw boys. She said, My
girlfriends choose either the grunges or the sexy, tough black boys. I like neither.
As her weight dropped dramatically, Grazia became extremely frightened and
withdrawn. She began plaintively crying throughout some sessions. Grazia
adamantly said,
I dont want to die, but I want to starve. I dont want to eat or drink except to have
enough energy to live. I like to hear my stomach rumbling. I like the pain of starvation. I
enjoy it. I feel strong when I am in control. When I lose control I feel weak.

Grazia went on to elaborate: If I am not dieting my mind gets lled with too much,
it is terrible, too upsetting, a lot is happening. But Grazia wouldnt talk about what
was troubling her. She then refused to come to the therapy, because her worried
psychiatrist intended to continue weighing her when she came to her hospital
appointments. Terried of putting on weight again, Grazia proclaimed, I will either
kill myself or immediately run away if I am put into hospital. Fierce rows over
eating escalated between Grazia and her mother resulting in her mothers
succumbing to Grazias refusal of both eating and hospital appointments. Feeling
completely frazzled, her mother also refused to collaborate with the doctors to
challenge Grazias decision to avoid inpatient treatment.
Feeling desperately concerned I made a series of phone calls in which I
acknowledged that although Grazia was adamantly dictating one course of action,
she was also isolated and frightened by what was happening. I suggested that she
deserved to be understood. Finally I was able to help Grazia to come to a therapy
session. In desperation, during this therapy session, I reversed roles with her, asking
her to be the psychotherapist while I would be the patient. While in this role I rmly
asserted, My body is dehydrated, I am starved, I want to do things by myself, I
dont want help from anyone. Grazia, in her role as psychotherapist calmly said,
You need to get some help looking after yourself, this isnt working! In my role as
patient, I argued, I will kill myself or run away if I go to hospital. Grazia replied
authoritatively, You dont want to go to hospital, but you need to.
I then resumed my role as psychotherapist and queried, You have such a
sensible voice as a psychotherapist, what is dierent when you get into your own
mind? Grazia replied,
The worst thing would be for my body to look healthy while I feel in such a state inside.
It would feel even worse. At least in this way, both inside and outside are the same. I will
be ill forever.

Then she quietly added, I might blame people and I am frightened to do that.
After a brief silence Grazia wistfully added,
I have such a maladjusted family. There is so much unhappiness at home with everyone
ghting. I really miss my father who at least provided some structure in the home,

Journal of Child Psychotherapy


stopped quarrels between family members, provided some authority, cooked the meals.
Now only I take on that role. My mother provides no food, no discipline, no structure.

Eventually, during the course of this session, Grazia agreed that to stay alive she
required the daily benevolent authority of doctors and nurses in the inpatient unit.
Shortly thereafter, she handed me a sheet of paper which read:
I hate myself. I hate me. I hate fat.
I hate my body. I hate myself. I hate myself.
I hate.
Fat idiot. Its all my fault. I deserve everything I get.
Fat and ashamed.

She then described two dreams:

Dream One:
I dreamt of a house getting smashed by a group of rough boys.
I hated the couple who didnt protect me from them.
Dream Two:
I cut myself and a boy grabbed my cut arm and swung me around.

Grazias expressions of hate, stupidity, messiness, fat and shame were all concretely
directed to both her psychological and her bodily self. Grazia was also describing the
state of her internal objects, which she was bringing to psychotherapy to be healed
(Rey, 1994). She was bringing both a damaged body and destroyed persecutory
internal objects in which all goodness was gone. There was nothing left but utter
desolation. In the dream, the boys, representing parts of Grazias anorectic and
destructive self, and perhaps actual boys, seemed to be creating a lot of damage to
both her physical body and her psyche. It was striking that Grazia projected
aggression and directed aggression to herself in moments of emotional crisis;
however, the dreams reected more than these internal diculties.
As part of a long discussion regarding the contents of the diary sheet and her
two dreams, Grazia disclosed that during the previous two years she was being
raped weekly by two African young men who knew her father and threatened
that, if she gave away their identities, they would both kill her and report her
father to the police for his criminal activities. Subsequently Grazia had many
regular discussions with a social worker, but she refused to identify the young
men in order to protect her father. She was afraid to tell her parents about the
abuse partly because she feared that her father would kill the men and then end
up in prison himself.
I would now like to explore various crucial factors, including the sexual abuse,
which contributed to Grazias diculty in developing a healthy female sexual identity.
The importance of the fathers role
Ideally, from birth, the father is involved with his daughter as a third person
mitigating the intensity of the motherinfant relationship (Trowell and Etchegoyan,
2002). In normal development, pleasure at the birth of a child is accompanied by
feelings of envy and exclusion from the intensity of the early motherinfant
relationship. A father can draw on his own maternal ability to act as a container for


J. Magagna and T.P. Goldsmith

the mother, to support her in caring for the newborn at this stage. In Grazias home,
the father had to take on the roles of the mother, as his wife suered from postpartum depression and later clinical depression.
In normal circumstances, the father can gradually develop a more active,
masculine role. This involves the father staking a claim on his child (Campbell,
1995) in order to help her to move from the exclusivity of her relationship with her
mother to an inclusive position as part of a pre-Oedipal triad. While her mother
represents the pre-Oedipal state with all its attendant anxieties, her father can excite
the young girls interest in the outside world. Moreover, the three dimensional
character of the combined object mother and father with baby can create the
foundation for the establishment of the infants own internal objects and all future
object relations (Ermann and Lazar, 2002). In the absence of a competent mother,
Grazia, however, formed an Oedipal partnership with her father (Ambrosio, 2005).
Freud recognised the little girls attachment to her father as providing a refuge
from her rst attachment to mother (Freud, 1931). Generally, the good-enough
father oers a second potentially rich and fullling relationship, an exciting and
attractive alternative to the childs regressive wish to return to a fused state with
mother. However, the arrival of this notion of a third creates diculties of its own.
Usually the third changes the dyadic relationship to the mother and requires the
infant to relinquish the idea that she is the sole possessor of the mother, leading to a
profound sense of loss (Cooper and Magagna, 2005). In Grazias situation, her
primary attachment was to her reasonably adequate father and her mother was the
rival third in her relationship with her father (Gluckman, 1987).
In order to develop, the baby girl nds ways of coming to terms with the loss of
this exclusive dyadic relationship. The other parent may be able to help the infant
tolerate these feelings. With a present second parent, the infant can risk hating the
primary attachment gure, because there is someone else to keep her alive
(Winnicott, 1964). Wisdom (1976) described the role of father in helping the child
to accept frustrations, and to bear distressing events without being overwhelmed by
them. He associated this with the introjection of the role of the father as opposed to
introjection of the nurturing functions of the breast and considered that this was
crucial in enabling the child to move from the paranoidschizoid experiences to those
of depressive concern for the motherfather relationship. As is the case with some
single parents, in the presence of an inadequate mother, Grazias father had the task
of providing both the nurturing functions of the mother and the limit-setting
thoughtful role of the father required to regulate emotional states.
The quality of this early infantile containment is tested again as Grazia enters
adolescence. She is faced with the fact that had her father been physically present she
would now have the physical and sexual capacity to realise her Oedipal desires with
her father, both sexual and destructive. Her longing for her father, and revival of
these original feelings is intensied by the dramatic physical changes of puberty. The
fathers role could have been to modulate Grazias possessiveness, jealousy and hate
towards the parents, and help his daughter think about her ambivalent ideas about
growing up and becoming independent. However, Grazias father had completely
In particular, as his daughter enters adolescence, Grazias father could have
assisted her in navigating a fundamental shift in her relations with the outside world
that occurs as she matures physically. He could also help her in overcoming another
profound loss: that of the loss of childhood and a childs sexually undeveloped body.

Journal of Child Psychotherapy


As Grazia developed the physical capacity to take on a sexual role, she could have
sought ways of experiencing her new body as gratied, loved and appreciated in
reality or in phantasy by her father in order to avoid the anxiety that threatened to
overwhelm her when she felt unable to achieve this. A good enough father would
have oered Grazia a chance to test out new parts of herself and new emotional
possibilities in relations with others (Waddell, 1998).
The role of the father is especially crucial to young girls achieving separation and
individuation from the mother during adolescence. Grazia was identied with a
damaged woman, a mother lacking the emotional and intellectual resources to foster
her development. Her internal mother with whom she identied was also attacked by
Grazias Oedipal jealousy and rage about her mothers inadequacies. Grazia, like all
young girls, needed to feel that her father was attracted and pleased by her
attractiveness both physically and emotionally whilst not experiencing the father as
being seductive towards her (Laufer, 1989). By giving Grazia the feeling that she could
be an object of desire, her father could help solidify Grazias feminine identity (Ritvo,
1976). However, Grazias father had completely abandoned her. In a study of the life
histories of women who have developed independent careers and lead a meaningful
family life as well, Tessman (1989) found that the fathers were described as stimulating
their daughters curiosity and independent judgement, and involving them in joint
endeavours. This is a task that begins long before the onset of adolescence. Indeed this
engagement is with the ghosts in the fathers own nursery, starting long before the
birth of a daughter. For a man, the pregnancy of his wife may form the stimulus for
him to revisit, as an adult, issues surrounding female sexuality and the capacity to bear
children. The father-to-be may feel that this is a mysterious power, a form of creativity
that is closed to him. He may feel excluded, simply a stud for his wifes pregnancy, and
may take refuge in the patronising attitude that his wife is no more than an incubator
for his child (Fast, 1979). The fathers denial of the importance of the maternal role
may damage the value of the mothers maternal functions in the young girls mind.
Grazias father had indeed denied sexual dierences and the importance of the
maternal role in choosing a clinically depressed young woman whom he would have to
replace in parenting his children.
In Grazias adolescence, fear of loss of her self became heightened as her body
underwent dramatic transformation. Micati Squitieri (1999) has shown how, when
the self is felt to be precarious, the body too can come to be seen as wounded, with
the absence of a penis coming to form the symbolic representation of this for a girl.
Grazia certainly hated having a womans body like her damaged and denigrated
mother. To compensate for this, Grazias defensive phantasies of having some
qualities of a hard, rm male body were intensied and led to her concretely holding
onto a stick male body to avoid the soft vulnerability of a feminine identication.
An absent, abandoning father
Chiland (1982) has rightly noted that the eects of an absent father on a girl must be
considered in relation to the qualities of her particular mother. Grazias mother was
not in a good frame of mind inadequate, severely depressed and unavailable to her
daughter. In this situation, the role of Grazias father throughout her development
became even more crucial. It was his task to hold Grazias aggression safely, so that
she could move towards a more depressive state of mind. What are the implications
of the absence of the father for Grazia? As an abandoning father, he only served to


J. Magagna and T.P. Goldsmith

increase her hostility. However, Grazia idealised her absent father and denigrated
her depressed mother. Because her idealised father was absent and her depressed
mother was so fragile, Grazia mainly directly her overt hostility towards her
internalised parents, her emotional life and her body. These attacks created
damaged, persecutory internal parents from which emanated a sense of internal
terror, persecution and dread (Meltzer, 1973). She obliterated thinking about
emotions and resorted to omnipotent control to feel safe in the face of her terrors.
There are many dierent kinds of absent father: those who remain in weekly or
monthly contact and those, like Grazias father, who have entirely rejected their
family and do not maintain any communication. If Grazias father was absent, but
could come back and think with her, Grazia would have had the possibility of taking
in the idea of a helpful, present, third. Her father could have still fullled his role of
arming his daughter in the concrete way that is of vital importance in enabling
healthy development as she entered adolescence and developed normal relations with
her male peers (Burgner, 1985). However, in Grazias situation, the father not only
traumatised the family by abruptly disappearing, but he also left them without his
paternal/maternal roles of looking after the family. He had become fed up doing
everything for everyone and both nancially and emotionally neglected Grazia and
her family. This was a narcissistic blow to Grazia who felt that if she had been good
enough, her father would have stayed.
Studies of the young one-parent child and of adolescent girls in treatment found
that absence or non-participation of a father frequently leads to overt overidealisation accompanied by inner phantasy of a terrifying and sadistic father
(Leonard, 1966; Neubauer, 1960). This sadistic father is created through rage
towards the absent, neglectful father. With a present father, the girl can go back and
forth, testing her internal world against the reality. In his absence, the picture
becomes very black and white. Without the opportunity of testing her phantasies
against the reality of a more benign, limit-setting, paternal presence, Grazias
aggressive and sadistic father prevailed internally. Simultaneously her absent
abandoning father was consciously idealised, and Grazias guilt and anger at his
abandonment was split o to gnaw away at her internalised father and her selfesteem in identication with her internalised father.
The sexual abuse by men and her absent abandoning father created even more of a
bad penis lled with her projected anger and hate. A similar example of this
projected anger and hate is found in Sylvia Plaths poem, Daddy:
. . . the man who bit my pretty red heart in two
. . . I tried to die
And get back, back, back to you.
I thought even bones would do.
But they pulled me out of the sack,
And they stuck me together with glue.
And then I made a model of you,
A man in black with a Meinkampf look

(Plath, 1981)

This poem bristles with rage and bitterness against her father who died when Plath
was 10 years old. Her very intense hatred of him may be seen in part as a projection
of her own rage. Plath may have attempted to externalise these murderous feelings in
order to cope with them in reality, rather than working through such raw emotions.

Journal of Child Psychotherapy


Of Plaths own marriage as a model of her relationship with her father (Plath, 1981)
she wrote in the same poem: I made a model of you/A man in black with a
Meinkampf look/And a love of the rack and the screw. In the poem, The father
gradually becomes little more than the principle of sadism, and the girl-speaker little
more than the principle of masochism (Lord and Stone, 1973).
If the father is not suciently present or alert to his daughters needs, in infancy
and then in adolescence, the anxieties resulting from an early failure to separate from
her mother may be revived in adolescence with renewed force. Campbell (1995)
described the analysis of a pre-suicidal patient, for whom separation from his mother
and individuation proved too painful. His mothering object was perceived as
untrustworthy and dangerous, and his father as aloof and distant. As was the
situation for Grazia, he was abandoned by his father to the mercy of a damaged
mother. The patient was then left at the mercy of profound, primitive anxieties: the
terror of being engulfed by the maternal object if his wish to merge should succeed;
and the fear of being left to starve if he did not.
With such a patient, and likewise with Grazia, the damaged maternal object
became identied with the body. Campbell (1995) notes that although there are
dierent types of suicide fantasies, each is underpinned by the fantasy that a part of
the self will live on, merged with an idealised maternal imago, and that this kind of
survival was dependent on the destruction of the actual physical body.
The inuence of sexual abuse linked with inadequate mother and absent father
In Grazias situation, sexual abuse by another male followed abandonment by the
father. It was easy to see how she might come to feel that her own sexual
development is almost life-threatening, for when sexual abuse occurs after a bad,
abandoning father has already been internalised, the external father can oer no
reassurance to his daughter as she approaches sexual maturity; furthermore, his
leaving has reinforced in her mind the idea that men leave wives and men are callous
and uncaring. Grazias mother, with whom she would identify as a sexually mature
woman, was not good enough to keep her father. Then, sexual abuse interferes with
any introjection of a good father that did take place, and the presence of a bad man
casts a powerful shadow over all psychic reality and all future relationships with
The absent, abandoning father left Grazia vulnerable not only to the damage
done to her self-esteem by the lack of a reassuring paternal presence, but also, his
leaving his wife created further damage done to her identication with her
already damaged internal mother. Grazia could not turn to her parents to talk
about the traumatising sexual abuse because she had developed an internal image
of a useless parental couple. In addition, she feared her fathers uncontained
violence which also contained her own projected and internalised violence. As in
Plaths (1981) poem, Grazias hatred and profound disappointment in her parents
makes them less adequate as internal helpers than her actual parents might have
been. She is left lacking the equipment to deal with sexual development and
It is too painful to explore the new relationships that come with adolescence.
Initially Grazia could have no boyfriend, because of her experience that husbands
leave wives, and no sex, because this was equated with her repeated abusive
experiences of rape, which reinforced her phantasies of the internalised parental


J. Magagna and T.P. Goldsmith

couples intercourse already ravaged by her own hostility towards the couple
(Meltzer, 1967). Thus isolated from establishing relationships with the opposite sex
in a normal, age-appropriate way, Grazia moved towards a lonely omnipotent
identication with an idealised absent father accompanied by sense of a persecutory
bad penis. Her image of a bad penis, coupled with her sexual abuse, made developing
sexual attractiveness a treacherous task and her anorexia became a natural outcome.
Grazias body, already identied with a damaged mother, also became bad because
it was lled with sexual abusers and rapists. She had no idea of how she might attract
someone who might help repair the damage. So the clock stopped and Grazia became
xated to a regressed state of being a little girl. She created a protective psychic retreat
to avoid the pain and terror of working through the damage. The bad penis inside
Grazia then became externalised and concretised in her unclear involvement with two
men who regularly raped and terrorised her. When she entered psychotherapy
emotionally immature Grazia had a hard, masculine self, an omnipotent self (Rosenfeld,
1987), which was designed to compensate for the absent father, unavailable mother and
the inner terrors intensely magnied by the external aggressors, the abusing men.
Phase Three: Beginning to develop an inner mental space for linking sensations,
feelings and thoughts
The counterpart to the idealised, absent, abandoning father was Grazias denigrated,
depressed and inadequate mother (Kestenbaum and Stone, 1976). Grazia hated but
at times concealed and denied her hatred of her mother for not being good enough
for her and for her father to stay. She would have only have a more depressed,
alcoholic mother to look after if she directly showed her anger to her mother. Since
after her fathers departure, Grazia had become the little boss at home it was very
dicult for her to see any reason not to be in control and to be free to do as she
liked. She disliked stupid thinking about things.
As an inpatient, Grazia was protected from some external traumas to her body
and psyche. This enabled her to become more involved in trying to think about her
inner experiences. She did not have such a need to focus upon her anorexia and her
academic work, both used as omnipotent defences to survive the failure of damaged
internal parental gures to process, regulate and integrate her emotional experiences.
While in psychotherapy, Grazia made fun of some of her dreams as she described
Dream Three:
I dreamt that I brought my eight-year-old cat to church.
Dream Four:
I dreamt of being with an English teacher who is rushing around, too busy to
eat. Someone leaves a baby with her, but she doesnt have time for the baby.

I sensed that Grazia was mocking the psychotherapy when she linked therapy with
going to church. Initially she was not so interested in the idea that I might help her
understand her emotional life. She desperately clung to the notion that she must count
on herself and on her own bright mind. Having insecure attachments to disappointing
parents, Grazia remained afraid, distrustful and competitive with me, her
psychotherapist. I bravely commented that she had some idea that there was a little
girl who could be brought to therapy, a little girl who lacked good parental care. Now,

Journal of Child Psychotherapy


what I oered to her, twice weekly therapy, seemed so little for the baby in her that
needed and wanted so much more. I talked about the propaganda issued by her
omnipotent self that said I didnt have time for her. We also talked about how, in
identication with unavailable parents, she had not eaten and actually only
considered her intellectual life. Her baby self remained abandoned as she had for so
long kept secret the abandonment by her father, the neglect of the children at home and
the sexual abuse. Moreover, until she was literally dragged to the hospital, she hadnt
been to a doctor or dentist for years, since her father had abandoned the family.
Subsequently, Grazia revealed her terrors as she described how her mother had
recently gone mad and tried to strangle her. Grazia bit her mother to prevent this
from happening and later arranged for her to be admitted into a psychiatric unit.
Grazia reported, I have no feelings about my mother. I think I should feel sad, but I
just feel numb. My security in life has been my friends. She could not tackle her
feelings about her mother, but instead directed hostile feelings to herself saying, I
feel fat, horrible, ugly, greedy. She continued bringing dreams:
Dream Five:
I dreamt I was with three girls. We are standing next to three crosses. I am being pushed
over by one of the girls..

Grazia explained, I hate that girl (my patient) who runs faster than me. I hate
sharing you with the other girls. I want to cry. I feel useless and a failure, huge, fat,
grotesque, my body has had so much dirty sex that I feel rubbish.
As she became more fully aware of her dependency on the therapy Grazia
became hungry to be loved and in competition with the other patients to become
the illest, most worrying anorectic patient. She described another dream:
Dream Six:
I dreamt I was kissing an unknown teacher whom I really liked, a man.

Subsequently, on separate occasions, Grazia became sexually involved with several

boys. She embarrassedly mentioned that her wish to immediately have someone to
be intimate and close to her overtook any judgement about whether or not the boy
was to be trusted and about whether or not he cared about her. Grazia felt sad as she
realised the way she confused her longing for a good father and mother, her wish for
intimacy with me, her psychotherapist, and her desire for a trustworthy relationship
with a boy and as she acknowledged that the boys were oering her nothing more
than a sexual relationship.
As we approached my two-week holiday, Grazia was consumed with rage:
She complained: I dont know what to do with my rage. I feel out of control. Why does
my dad look after another family and not my family? What is underneath my anorexia?
I wonder, do I have schizophrenia, underneath the anorexia? What will happen if I let
go of my anorexia and my intellectual control, who will I be then? she asked. Then she
repeated, I am afraid I will just be a pig.

I described to Grazia how her hunger for compassionate understanding and care left her
feeling greedy. Grazias rage was linked to me, her departing therapist representing
depressed, unavailable mother and her abandoning father. I described Grazias rage and
greed as being connected to her wish to possess me completely, to have me just for herself.


J. Magagna and T.P. Goldsmith

I indicated her wish to get rid of my other interests, my partner, my other patients. I
acknowledged her worry about schizophrenia and awareness of something bad and
terrifying inside. I added that it was up to us to discover its nature.
Grazias fear of schizophrenia was linked with her lifetime history of trying to
please adults apart from her mother whom she secretly denigrated as a stupid
woman with no common sense. She feared that if she didnt placate me, her friends
and teachers she would be hated. Gradually though she brought the whole of her
infantile self directly to me:
Grazia entered university and had three essays to write for her comparative literature
classes. She screamed at me, You have got it wrong! Nothing you say is right! I cant
cope! You havent helped me at all. I cant do university level work. I want to give up! I
hate it here! I hate everything!.

In these two sessions as Grazia attacked the father and me, the stupid mother-me
who encouraged her to full her dream to go to university, her inner world became a
dangerous place in which she was again increasingly persecuted by bad inner objects.
Subsequently Grazia had a dream. Before she returned to therapy to report the dream,
she called me to say she didnt feel like talking anymore because she couldnt trust me.
Her screaming at me had resulted in her feeling very persecuted and she missed the
session. When she did return, Grazia described the dream:
Dream Seven:
My horrible bossy aunt and uncle are both screaming at me.

Now it was more obvious to Grazia that her own rage led to a feeling of inner
damage and persecution. She also became aware that feeling robust through
maintaining a menstrual weight and developing sexually was felt as bad, dangerous
and undesirable. Grazia, already had an inner space lled with bad internalised
parents, and she feared that showing aggression to me would lead to a concrete
repetition of her abusive history, an encounter with concrete, external, bad objects,
the bad persecutory penis/male.
The phantasy of an exciting penis, or the acting out with a sexual adventure, was
at times used by Grazia to deny painful feelings and to avoid the anxiety of
fragmentation and dissolution of the self (Meltzer, 1973). At times in this phase of
psychotherapy, Grazia chose to say yes to boys, her peers, who only wanted sex with
her. She also sometimes retreated to anorectic starvation routines because they gave
her an endorphin high.
Phase Four: The debate: to choose anorectic obliteration of feeling or to choose
mothering ones infantile self, compassionately comprehending ones emotional
experience thus creating the psycho-sexual possibility of becoming a mother
Grazia began menstruating and gaining weight as well as receiving top marks in her
comparative literature university studies. She began meeting up with both old and
new friends. Then she then had two dreams:
Dream Eight:
There is a couple, I am living with them. I am holding their baby. I then squish the baby
by mistake. I dont want to tell anyone, but I awaken and remember the dream.

Journal of Child Psychotherapy


Dream Nine:
I am trying to get to a class with a psychology teacher who is perceptive, interested in
the work, but a hedgehog hurts me. I end up missing the boat and not getting to the
class. Later in the dream I discover that one of my brothers has attended the psychology

We explored how something destructive interferes with Grazia holding, caring for
and developing from the insights she has gained in therapy. She denigrates herself
and what she has been given. Jealousy of another occurs. She then feels guilty and
worthless and feels she has missed the boat carrying her to a more fruitful life
including developing insight in psychotherapy.
Grazia subsequently brought an image of a couple talking together, with their
children exploring the surroundings, magazines around them. She started talking
about moving forward in her life. Then she grumbled, I cant though because there
is a rigid ribbon coiling round my brain, holding it in check. She said she had tried
to tell herself, Unwind the rigid ribbon that has become so entwined in your hair
that it has become a part of you. Grazia complained,
I am afraid to do this. I am so afraid of losing my anorectic identity. I want to stay a
little girl for fear I wont get any help from anyone, nancial help, therapeutic help, help
from friends.

Gradually Grazia began to develop some notion of a dierent way of being. She
When I meet my mother each week I feel a bit paranoid about what she will feel and say
about my wish to tell her what to do, my wish to have her all to myself. I guess I will
have to let her live her own life the way she wants to live it.

I told Grazia that she did often seem to feel the need to tell me what to think and say.
She did get worried about what I will think of this wish to boss me. I added that on
the other hand, I understood that sometimes I got it wrong, and she was obviously
going to have to help me understand how to get it right in terms of how she was
feeling. Also she was aware that she was having to create a life with friends herself
and that she had to let me have my life too.
At this moment, I became aware that Grazia was attiring herself a bit too old for
her age and rather identically to me, with the pearls and hairstyle consisting of hair
piled on top of her head. I realised that Grazia was aspiring to become a dierent
kind of person. She was trying to develop some of the sensitivity and thoughtfulness,
which she perceived as being present in our relationship. This gentler, more sensitive,
feminine way of being and feeling coupled and modied by thinking together with
me was dierent from Grazias taking control of her life by herself with piercing,
cutting omnipotent, masculine, intellectual control.
Grazia subsequently found a way of encouraging each of her divorced parents to
meet her separately for an hour or so each week. She also succeeded in helping them
become fairly reliable in meeting her. Grazia began seeing her parents again with
more acceptance of both their disappointing, limited capacities to parent her and
their minimal, but appreciated, concern for her. About her parents, Grazia said:
They are who they are and they are my parents. I guess I just have to accept this is
who they can be. As she became further involved in a discussion of her parents with


J. Magagna and T.P. Goldsmith

me Grazia said, I feel at, tired and a bit lost. She was having to mourn the
absence of external parents as she grew up.
This more realistic view of her parents was assisted by the fact that Grazias
needy and infantile destructive feelings were more fully accepted and understood in
therapy. When she alone did not have to bear the weight of all her intense feelings,
Grazia was able to gain weight:
I just sit in Costa Coee looking at a group of mothers with their babies. I think, I
want to be a mother, I want to have a baby, I want to have a family. I need to eat in
order to do that. These hopeful thoughts inspire me to eat more normally.

In another session Grazia lamented,

I have a lot of friends, boys and girls. The problem is that when I start thinking of
having a real boyfriend I immediately get worried . . . will he like me, will he just want a
ing or will he just drop me because of who I am and what my family is? I dont want a
ing and I dont want rejection.

I talked with her about how there was a little hope which enabled her to think about
having a boyfriend. She was trying to think about it sensibly, realistically, but at
times the voice of despair settled in and made it dicult to take hopeful steps in her
At the end of this period of psychotherapy Grazia, did nd a boyfriend with
whom she enjoyed the pleasures of a trustworthy intimacy and interesting cultural
experiences; however, subsequently Grazia, her mother and brothers returned to
Italy to live with the maternal grandparents. With my help, Grazia has found a new
psychotherapist in Italy and she is successfully continuing to develop as she pursues
her university studies.
I have described how part of the work of psychoanalytic psychotherapy with an
anorectic adolescent girl involves retracing and re-working the stages of early
emotional development in the transference to the therapist. The other part of the
work involves learning more about how the omnipotent destructive part of the
personality and other parts of the personality attempt to achieve psychic
equilibrium rather than emotional development of the personality. An anorectic
girl with a false self faces many complications in developing a stable female sexual
identity. Initially the presence of an attacked and damaged combined parental
gure and damaged internal babies creates inner terror. The haunting monster,
the rapist, existing both in the girls internal world and in the form of external
sexual abusers is masked by a masculine, hard, controlling, little dictator
omnipotent self. At times the self masquerades as a hard Hitler, a seductive
female, a studious saint or simply as a little girl with a fragile self. The therapeutic
work in each session is thus complicated by a sense of dissociated identities refusing
to acknowledge the presence of other parts of the self.
The masquerades are created through aggressively entering the mother gure,
father gure or sibling gure and projecting into others ones feelings of rage,
jealousy, love, hate and over-protectiveness. The therapist must constantly use the

Journal of Child Psychotherapy


countertransference to be emotionally present to the anorectic girls discordant

symphony of competing states of mind (Alvarez, 2008).
There is considerable countertransference pressure on the therapist to remain
claustrophobically trapped with the young girl in the musings of anorexia nervosa
that can control everything . . . weight, shape and feelings. When a crisis occurs and
there are overwhelmingly intense emotions, the anorectic obsessional thoughts about
fear of fatness and feeling disgusting forcefully occur and strangle the healthy mind.
When encapsulation of patient and psychotherapist through anorectic conversation
occurs there is a starving of the infantile self requiring understanding (Magagna,
2000). In the assessment session, I showed the sense of emotional impoverishment
felt underneath this omnipotent intellectual control and anorectic thinking and
behaviour. Anorexia nervosa pretends to oer protection but ultimately it provides
breakdown of physical health, loss of proper neurological functioning and also
claustrophobia, feelings of misunderstanding and the loneliness of existing in a
vacuum with certain states of mind.
To achieve an appropriate female sexual identity, Grazia began to nd ways of
coming to terms with the lovehate relationship with me, her psychotherapist
representing the internal parents. Initially, because of her emotionally and physically
abusive external life and her internal experiences, Grazia was consumed with the fear
of unreliable, uncomprehending parents as well as the physical and emotional
trauma of repeated sexual abuse. As time progressed, Grazia had the task of
introjecting the compassionate comprehension of internal motherfather roles
combining feeling with thinking. Moreover, she has had to traverse emotional paths
so dierent from her early patterns of development. After various regressions to
anorectic behaviour and sexual acting out, gradually through psychotherapy Grazia
began to identify with the mother who can love and look after the baby and contain
the babys anxieties as well as with the mother, as a wife, allowed the freedom to
have intercourse, discourse with the father and who can create/have other babies/
Dr Joan Symington (1985) described how the chance of a girl achieving psychic
independence without undue guilt and depression depends to a large extent on the
parents willingness to allow the girl to become independent and have her sexual
identication with the mother. The development of a female sexual identity is based
on the complex interplay between a girls perpetually present unconscious internal
family relations and her external environment (Laufer, 1981). Grazias absent
abandoning father coupled with her depressed, inadequate mother inuenced her in
becoming a little boss father at home with no compassion for feelings.
During a later phase of psychotherapy Grazia gradually relinquished the role of
being a little boss father in the sessions. Following my holidays there was a decrease
in her need to miss a session as a way of controlling the times for meeting and
projecting her rage and her sense of abandonment, her jealousy into me.
Not eating, fear of menstruation, fear of breast development, hatred of the male,
lesbianism and infertility all have been shown to have psychological implications
linked with envy of the breast and its riches, hatred and separation from the mother,
jealousy of the mothers babies and oral, anal and genital attacks on the internal
family members. The neglect, inadequacy and lack of comprehension of external
parents as well as the existence of internal persecutory internal gures, lled with
destructive projections, can result in an inability for a girl to aspire, to identify with
mother, to become a wife with ones own husband and a mother of ones own


J. Magagna and T.P. Goldsmith

children. Proceeding to marry and have children while having damaged internal
parents often results in repetition of failures of the previous parentchild relationships as is shown in Alan Steins (1994) studies of anorectic mothers and their
The progress in the development of a healthy female sexual identity is further
complicated by extreme deprivation and abuse. Sadistic revenge (a common
problem) in very deprived, abused girls is dicult but essential to modify in
psychotherapy. For an adequate female sexual identity to develop it is essential to
develop a quiet, inner and painful taking over of ones self, daily worrying about
who one is being with the self and others. Remorse is essential for reparation of the
damaged self (Murray-Cox, 1999). Grazia at times was able to say, thank you for
staying connected to me. Sometimes I am really nasty. I am sorry.
Internal family relationships present in a girls dreams, will reveal the nature of
the girls female sexual identity. Compassionately comprehending the young persons
dreams as a reection of the developing relationship with the psychotherapist as well
as giving a picture of external realities of a young anorectic person will assist in
noting and predicting diculties in treatment and noting stages in her sexual
In writing this paper, I have highlighted aspects of development in therapy to
illustrate some of Melanie Kleins (1945) ideas regarding early Oedipal anxieties, the
roles of the damaged mother and absent father in inuencing the development of a
healthy female sexual identity. Implicit in my work is the understanding that the
therapist, like a parent, must address the infantile self as well as more mature aspects of
the developing personality, to help the young anorectic girl integrate and regulate her
emotional life, her love and her hate (Schore, 1994). External physical, social and
academic progress can mask the lack of internal development. However, we have a
moral responsibility to provide compassionate comprehension for the immature
developing child within the anorectic adolescent . . . a moral responsibility not only
to help an anorectic young girl to regain her physical health by eating, but a moral
responsibility to nd ways to establish inner development through psychotherapy for:
The child, a child of lifes longing for itself, will be responsible for the next generation of
(Gibran, 1933)

I would like to express my gratitude to the heavily disguised patient, Grazia, and Dr Anne
Alvarez who supervises my clinical work with patients and also to Tara Pepper Goldsmith and
Ellen Jae who helped with the writing of this paper.

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