In Monday’s New York Times psychiatrist Anne Skomorowsky offered an interesting account of what happened one day when she was working with an anorexic patient.
As you may know, anorexia is treated with food. Since most anorexics will avoid ingesting food at nearly any cost, many treatment centers force feed them. So it is today and so it has been for decades. Skomorowsky learned about it two decades ago.
When instructed to force feed an anorexic, she recalled a movie she had recently seen, “The Titicutt Follies.” In it, the process is shown in all its ugliness:
In one of the most grueling scenes, a patient who has refused food is held down by guards, and a fat nasogastric tube is shoved into his nose. A white slurry of nutrients is poured into a plastic funnel at the other end of the tube. A doctor flicks his cigarette ashes into the funnel as the food goes down.
When Skomorowsky expressed her reservations to the psychiatrist who was heading the unit she received this reply:
She explained that it was a voluntary unit and that patients who agreed to be treated there had consented in advance to tube feeds if they would not eat. She also explained that a starving person had lost capacity to reason. At such a low weight, the patient could not make rational decisions, and thus could not be allowed to refuse lifesaving treatment — in this case, food.
It is important to understand that when an anorexic starves herself—most often the patients are female—her malnourishment affects her brain and her mental capacity. It compromises her ability to make rational decisions. Undoubtedly, it also makes it impossible for her to understand how emaciated she really is.
Given the patient’s impaired mental capacity, many psychiatrists draw the wrong conclusion. They believe that when a patient cannot reason it is not worth the effort to try.
Skomorowsky tried a different approach. She did not reason with her patient, but explained in graphic detail what it was like to be force fed. For emphasis she dramatized the process and made it sound like a rape. She then confessed that she herself was not very good at it:
I told her that to prepare for my residency, I had done a yearlong medical internship, during which time I had struggled to place nasogastric tubes. In fact, I explained, I had never done it properly. I would lose my nerve when a patient recoiled, and the tube would not make it into the stomach, but emerge through the mouth. I asked this patient to imagine what it would be like to have five men holding her down while a tube was smashed through her nostrils. I used what I had seen in “Titicut Follies” to describe a scene in which the patient would be violated and helpless.
It is fair to say that this is a threat. It is an effort to intimidate the patient. It rejects the patient’s assertion that she does not want to eat and declares that she is going to eat, one way or the other.
Given Skomorowsky’s description the patient chose to eat voluntarily.
What did the young resident really do? She tried out a new rhetorical strategy. And she backed it up with a threat of force. It is fair to say that any psychiatrist, properly trained, could employ the same strategy.
At the least, there is nothing about this approach that would lead you to think that the patient changed her mind because of a flash of Freudian insight. Nor is there anything about it that would lead you to believe that the psychiatrist was motivated by some Freudian insight into her past.
Yet, when Skomorowsky tries to examine what happened in her article, she cannot take credit for an inspired intervention. Strangely, she shifts the credit to her psychoanalyst.
Her thinking matters because it shows how psychoanalysis distorts mental processing and makes it impossible for her to think straight about her own experience. After all, she is less concerned with why her strategy worked than where it came from and why she thought of it.
First, Skomorowsky explains that the real reason she did not want to force feed her patient was that she was suffering from a phobia about vomiting. She was terrified that her patient would vomit.
Of course, there is nothing about a vomit phobia that would lead one to adopt the rhetorical tactic that she chose. One can easily imagine that someone who had seen the process in a movie would be inclined to exhaust all alternatives before violating her patient’s nasal passages.
After all, she might also have developed a counterphobic reaction and become an expert in the deployment of feeding tubes.
Nothing about the phobia, its acceptance, its denial or its overcoming could have led her to develop a new and more effective rhetorical strategy.
To think otherwise is not to think.
Then, Skomorowsky errs in trying to give credit to her psychoanalyst. Happily, she states that psychoanalysis cannot treat or cure phobias. No rational being thinks that it can. She knows that only exposure and desensitization can help a patient overcome a phobia.
In her case she dealt with her phobia while being an intern and a resident. She was forced to be exposed to vomit and she dealt with the problem because it was her duty as a physician.
Reasonably, she had chosen to specialize in psychiatry, that being the specialty most likely to shield her from vomit.
She was wrong:
I had imagined that once I was a psychiatrist, the problem would be moot. I was mistaken. To my surprise, hospitalized psychiatric patients gagged, too. The medications they took could make them choke on their food, and when they overdosed on pills, they were fed a nauseous black slime of activated charcoal that bound the pills so they could not be digested. I still felt impaired by my phobia.
Finally, Skomorowsky tried to find a place for psychoanalysis in the process:
Psychoanalysis tends to move about in time, with the focus shifting between formative experiences and the patient’s daily life. I spoke with my analyst about my past, of course, but the goal was to get better at managing the present. I felt that childhood problems that should no longer have relevance — my phobia, my dislike of being told what to do — had undermined me as a competent adult.
As we unpacked the incident, I began to see that what had seemed like my weaknesses had actually been beneficial to the patient. My phobic avoidance of nasogastric tube placement had become a means of standing up for my own and my patient’s autonomy. “Titicut Follies,” my phobia, my aversion to authority and the needs of my patient had converged that night on the eating disorders unit. I told the patient the truth about myself and about her own powerlessness at that moment. The patient and I had an honest conversation, and no force was necessary.
Let’s try to understand these two paragraphs.
First, she has discovered that her childhood problems are not relevant to the present.
If so, why spend all of that time dredging them up? Why not do a better job teaching young psychiatric residents how to speak with their patients? If trauma is not relevant, why do psychoanalysts insist that traumas need to be integrated into a new self-narrative?
Second, she is wrong to believe that anyone’s autonomy is involved. Not even close.
Neither the patient nor the psychiatrist had any real autonomy. The patient was going to be fed, one way or another. The patient could choose, but her choice was clearly made under threat.
If the strategy did not arise from her gut like so much mental vomit, where did it come from?
It is reasonable to believe that Skomorowsky had seen someone else use it in a different circumstance. It might even have been used on her.
We have all, at one time or another, been children. And children, lacking a fully developed capacity for rational decision making, are often faced with a choice between doing something voluntarily and being coerced.
Besides, Skomorowsky did not act irrationally. She was not crippled by anxiety. She acted rationally. Had her behavior been defined by a phobia it would not smack of rational thought.
Also, she and her patient did not have an honest conversation. When I tell you that either you are going to do what I want to do or I will force you to do it, we are not having an honest conversation. I am persuading you with the only means that you can still respond to.
As for the tactic of honestly explaining that she was not very good at force feeding, she might have been opening herself for a malpractice suit. Or, she might have found herself facing a patient who wanted to have a new psychiatrist.