(2009).

Journal of Child Psychotherapy, 35:62-80

Complications in the development of a female sexual identity

Jeanne Magagna * and Tara Pepper Goldsmith
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.

Introduction
An anorectic girl's development of her female sexual identity and the influential 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, Grazia. 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 reflective understanding. I am struck by how, as the group begins, they don't 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 difficult moments, those difficult moments in which conflict, aggression or psychic pain has been revealed. They often say, I just don't 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 find it difficult to differentiate 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 differently. They might wear the clothes of little girls or the permanently present tracksuits oflatency-age boys or style their hair in pigtails. Others have sexually developing bodies, use make-up, wear pop star trendy clothing of tight lowcut jeans and short

* Corresponding author. Email: jm@hoping.demon.co.uk

- 62 -

t-shirts, and have pierced ears, tongues, noses or belly-buttons. At the beginning of the group, each girl firmly 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 specifically, there is a certainty that the adults will not recognise that the academically able adolescent girl is not psychologically ready to be grown-up. 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 firm, 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 girl's 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 fine 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 difficulties 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 Simon's lyrics: I've 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 suffering from severe weight loss and anorexia nervosa, each girl has a unique personality, a particular family narrative, different responses within herself and different interactions with significant 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: 1. The experience of the self as a very fat and ugly person 2. The skinny, starved self caged in by omnipotent control 3. The self emerging with persecutory anxieties, fears of attack and rape 4. The wish to be in the middle of the parental couple, splitting them up, rather than maintaining the generational boundary between parent and child 5. Possessive jealousy of primary caregivers' relationships with siblings
- 63 -

6. More integration of split-off parts of the self 7. Development of a healthy female identity comprised of identification with good parental figures. This more spontaneous drawing of the normal adolescent female body suggests a spontaneous interplay between one's bodily sensations and feelings and a compassionately comprehending self. Although underneath uniquely different 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 sufficient to assist a very emotionally deprived and sexually abused anorectic adolescentgirl develop a healthy female sexual identity? Can psychoanalytic psychotherapy provide sufficient compassionate comprehension to give meaning to this girl's 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 girl's 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 shoulder-length 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 Grazia's alcoholic father, a car mechanic, was fleeing from some financial 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 father's 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 hermother. Grazia's traumatised and depressed mother did not pursue him to give any money to the family so they were financially bereft.

Phase One: The psychotherapy assessment

Grazia, severely emaciated and suffering from anorexia nervosa was accompanied to her first hospital appointment by her 37-year-old mother. Her confused, uncertainmother seemed like Grazia's daughter, for the mother appeared completely under Grazia's control. Prior to Grazia's birth, the mother had experienced severe clinical
- 64 -

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 flat. 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. Grazia's 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. Mother's depression, alcoholism and anxiety over being abandoned may have blinded her to the emotional dangers to Grazia in taking on this parentified role. Grazia's sturdy, omnipotent, bossy dad identification felt a developmental necessity for Grazia to survive the anxieties of lacking parents both externally and internally to nurture and support her. H owever, her bossy dad omnipotent identification 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 terrified 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 don't want to get better. I am not a therapy person, not a meal person, not a drinking person. In the assessment, Grazia firmly 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 haven't been abused by my uncles or any family members. I said that leaves some other possibilities, but she said, No. I offered two sessions of psychotherapy per week and mother attended family therapy alone because the father and the two sons refused to join her.
- 65 -

During the first 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 five years old and that currently she, her two brothers and her mother still shared the same bedroom. Grazia said, I've taken over dad's role. I look after my mother. During one year of psychotherapy, Georgia gained 8 kg and began menstruating. It was then, when the contraceptive effects 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 don't want to die, but I want to starve. I don't 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 filled with too much, it is terrible, too upsetting, a lot is happening. But Grazia wouldn't 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. Terrified 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 mother's succumbing to Grazia's refusal of both eating and hospital appointments. Feeling completely frazzled, her mother also refused to collaborate with the doctors to challenge Grazia's 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 firmly asserte d, My body is dehydrated, I am starved, I want to do things by myself, I don't want help from anyone. Grazia, in her role as psychotherapist calmly said, You need to get some help looking after yourself, this isn't working! In my role as patient, I argued, I will kill myself or run away if I go to hospital. Grazia replied authoritatively, You don't 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 different 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 fighting. I really miss my father who at least provided somestructure in the home,
- 66 -

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. It's 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 didn't protect me from them. Dream Two: I cut myself and a boy grabbed my cut arm and swung me around. Grazia's 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 persecutoryinternal objects in which all goodness was gone. There was nothing left but utter desolation. In the dream, the boys, representing parts of Grazia's 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 projectedaggression and directed aggression to herself in moments of emotional crisis; however, the dreams reflected more than these internal difficulties.

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 Grazia's difficulty in developing a healthy female sexual identity.

The importance of the father's 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. Afather can draw on his own maternal ability to act as a container for
- 67 -

the mother, to support her in caring for the newborn at this stage. In Grazia's home, the father had to take on the roles of the mother, as his wife suffered from post-partumdepression 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 girl's 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 infant's 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 girl's attachment to her father as providing a refuge from her first attachment to mother (Freud, 1931). Generally, the good-enough fatheroffers a second potentially rich and fulfilling relationship, an exciting and attractive alternative to the child's regressive wish to return to a fused state with mother. However, the arrival of this notion of a third creates difficulties 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 Grazia's situation, her primaryattachment 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 finds 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 figure, 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, Grazia's 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 intensified by the dramatic physical changes of puberty. The father's role could have been to modulate Grazia's possessiveness, jealousy and hatetowards the parents, and help his daughter think about her ambivalent ideas about growing up and becoming independent. However, Grazia's father had completely disappeared. In particular, as his daughter enters adolescence, Grazia's 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 child's sexually undeveloped body.

- 68 -

As Grazia developed the physical capacity to take on a sexual role, she could have sought ways of experiencing her new body as gratified, loved and appreciated in realityor in phantasy by her father in order to avoid the anxiety that threatened to overwhelm her when she felt u nable to achieve this. A good enough father would have offered 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 identified with a damaged woman, a mother lacking the emotional and intellectual resources to foster her development. Her internal mother with whom she identified was also attacked by Grazia's Oedipal jealousy and rage about her mother's 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 Grazia's feminine identity (Ritvo, 1976). However, Grazia's 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 father's 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 wife's pregnancy, and may take refuge in the patronising attitude that his wife is no more than an incubator for his child (Fast, 1979). The father's denial of the importance of the maternal role may damage the value of the mother's maternal functions in the young girl's mind. Grazia's father had indeed denied sexual differences 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 Grazia's 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 woman's body like her damaged and denigrated mother. To compensate for this, Grazia's defensive phantasies of having some qualities of a hard, firm male body were intensified and led to her concretely holding onto a stick male body to avoid the soft vulnerability of a feminine identification.

An absent, abandoning father

Chiland (1982) has rightly noted that the effects of an absent father on a girl must be considered in relation to the qualities of her particular mother. Grazia's motherwas not in a good frame of mind inadequate, severely depressed and unavailable to her daughter. In this situation, the role of Grazia's father throughout her developmentbecame even more crucial. It was his task to hold Grazia's 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
- 69 -

increase her hostility. However, Grazia idealised her absent father and denigrated her depressed mother. Because her idealised father was absent and her depressed motherwas 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 different kinds of absent father: those who remain in weekly or monthly contact and those, like Grazia's father, who have entirely rejected their family and do not maintain any communication. If Grazia's father was absent, but could come back and think with her, Grazia would have had the possibility of taking in the ideaof a helpful, present, third. Her father could have still fulfilled his role of affirming his daughter in the concrete way that is of vital importance in enabling healthydevelopment as she entered adolescence and developed normal relations with her male peers (Burgner, 1985). However, in Grazia's 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 financially 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 nonparticipation of a father frequently leads to overt over-idealisation 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, Grazia's aggressive and sadistic fatherprevailed internally. Simultaneously her absent abandoning father was consciously idealised, and Grazia's guilt and anger at his abandonment was split off to gnaw away at her internalised father and her self-esteem in identification with her internalised father. The sexual abuse by men and her absent abandoning father created even more of a bad penis filled with her projected anger and hate. A similar example of this projected anger and hate is found in Sylvia Plath's 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 projectionof 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.
- 70 -

Of Plath's 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 Meinkampflook/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 sufficiently present or alert to his daughter's 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 andindividuation 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 identified with the body. Campbell (1995) notes that although there are different 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 influence of sexual abuse linked with inadequate mother and absent father
In Grazia's 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 sexualdevelopment is almost life-threatening, for when sexual abuse occurs after a bad, abandoning father has already been internalised, the external father can offer 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. Grazia's mother,

with whom she would identify as a sexually mature woman, was not good enough to keep her father. Then, sexual abuse interferes with anyintrojection 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 men. 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 identification 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 father's uncontained violence which also contained her own projected and internalised violence. As in Plath's (1981) poem, Grazia's 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 maturity. 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
- 71 -

couple's 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 identification 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. Grazia's body, already identified with a damaged mother, also became bad because it was filled 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 fixated 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 magnified 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 Grazia's 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 father's departure, Grazia had become the little boss at home it was very difficult 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 figures to process, regulate and integrate her emotional experiences. While in psychotherapy, Grazia made fun of some of her dreams as she described them: 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 doesn't 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, - 72 -

what I offered 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 didn't have time for her. We also talked about how, in identification 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 hadn't 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 offering her nothing more than a sexual relationship.

As we approached my two-week holiday, Grazia was consumed with rage: She complained: I don't 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 the n? 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. Grazia's rage was linked to me, her departing therapist representing depressed, unavailable mother and her abandoning father. I described Grazia's rage and greed as being connected to her wish to possess me completely, to have me just for herself. - 73 -

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. Grazia's 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 womanwith no common sense. She feared that if she didn't 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 can't cope! You haven't helped me at all. I can't 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 fulfil 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 didn't feel like talking anymore because she couldn't 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: - 74 -

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 filled 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 offragmentation 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 one's infantile self, compassionately comprehending one's 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 don't want to tell anyone, but I awaken and remember the dream. 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 class.
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 inpsychotherapy.

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 can't 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 won't get any help from anyone, financial help, therapeutic help, help from friends.
Gradually Grazia began to develop some notion of a different way of being. She commented,

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 different 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 modified by thinking together with me was different from Grazia's 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
- 75 -

me Grazia said, I feel flat, 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 Grazia's 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 Coffee 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 fling or will he just drop me because of who I am and what my family is? I don't want a fling and I don't 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 difficult to take hopeful steps in her life.

At the end of this period of psychotherapy Grazia, did find 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.

Conclusion
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 personalityand 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 figure and damaged internal babies creates inner terror. The haunting monster, the rapist, existing both in the girl's 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 figure, father figure or sibling figure and projecting into others one's feelings of rage, jealousy,love, hate and overprotectiveness. The therapist must constantly use the
- 76 -

countertransference to be emotionally present to the anorectic girl's 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 offer protection but ultimately it provides breakdownof 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 find 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 different from her early patterns of development. After various regressions to anorectic behaviour and sexual acting out, gradually through psychotherapy Grazia began to identify with themother who can love and look after the baby and contain the baby's 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/patients. 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 identification with the mother. The development of a female sexual identity is based on thecomplex interplay between a girl's perpetually present unconscious internal family relations and her external environment (Laufer, 1981). Grazia's absent abandoning fathercoupled with her depressed, inadequate mother influenced 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 mother's 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 figures, filled with destructive projections, can result in an inability for a girl to aspire, to identify with mother, to become a wife with one's own husband and a mother of one's own
- 77 -

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 Stein's (1994) studies of anorectic mothers and their children. 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 difficult 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 one's self, daily worrying about who one is being with the self and others. Remorse is essential for reparation of the damaged self (MurrayCox,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 girl's dreams, will reveal the nature of the girl's female sexual identity. Compassionately comprehending the young person'sdreams as a reflection 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 difficulties in treatment and noting stages in her sexual development. In writing this paper, I have highlighted aspects of development in therapy to illustrate some of Melanie Klein's (1945) ideas regarding early Oedipal anxieties, the roles of the damaged mother and absent father in influencing 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 find ways to establish inner development through psychotherapy for: The child, a child of life's longing for itself, will be responsible for the next generation of children. (Gibran, 1933)

Acknowledgement
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 Jaffe who helped with the writing of this paper.

References
Alvarez, A. (2008) Types of sexual transference and countertransference in psychotherapeutic work with adolescence Unpublished draft Ambrosio, G. On Incest: Psychoanalytic Perspectives Karnac London 2005 Burgner, M. (1985) The Oedipal Experience: Effects On Development Of An Absent Father International Journal of Psycho-Analysis 66: 311-320 [] Briggs, A. Surviving Space: Papers on Infant Observation Karnac London 2002 Campbell, D. (1995) The role of the father in a pre -suicide state International Journal of PsychoAnalysis 76: 315-323 []
- 78 -

Chiland, C. (1982) A new look at fathers Psychoanalytic Study of the Child 37: 367-379 [] Cooper, C. Magagna, C. (2005) The development of self -esteem in infancy Intimate Transformations: Babies with their Families ed. Magagna, C. Bakalar, C. Cooper, C. Levy, C. Norman, C. Shank, C. London: Karnac Ermann, R.A. Lazar, R.A. (2002) From dyad to triad: Observations on the similarities and differences in the roles and functions of mother and father in infantile development The International Journal of Infant Observation 5: 383-100 Fast, I. (1979) Developments in gender identity: gender differentiation in girls International Journal of Psycho-Analysis 60: 443-453 [] Freud, S. (1931) Female Sexuality SE 21: 223-243 Gibran, K. (1933) The children Garden of the Prophet New York: Knopf Gluckman, C. (1987) Incest in psychic reality Journal of Child Psychotherapy 13: 1109-123 [] Kestenbaum, M.H. Stone, M.H. (1976) The effects of fatherless homes upon daughters: clinical impressions regarding paternal deprivation Journal of the American Academy of Psycho-Analysis 4: 2171-190 [] Klein, M. (1945) The Oedipus complex in the light of early anxieties Wri tings of Melanie Klein, Vol. 1: Love, Guilt and Reparation and Other Works London: Hogarth1975 Laufer, M. (1989) Adolescent sexuality a body/mind continuum Psychoanalytic Study of the Child 44: 281-294 [] Laufer, M.E. (1981) The adolescent's use of the body in object relationships and in the transference a comparison of borderline and narcissistic modes of functioningPsychoanalytic Study of the Child 36: 163-180 [] Leonard, M.R. (1966) Fathers and daughters the significance of fathering in the psychosexual development of the girl International Journal of Psycho-Analysis 47: 325-334 [] Lord, C. Stone, C. (1973) Fathers and daughters: a study of three poems Contemporary Psychoanalysis 9: 2526-539 [] Magagna, R. (2000) Individual psychotherapy Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence (second edition) ed. Lask, R. Bryant-Waugh, R. London: Psychology Press Meltzer, D. (1967) The Psychoanalytic Process London: Heinemann [] Meltzer, D. (1973) Sexual States of Mind Perthshire: Clunie Press [] Micati Squitieri, L. (1999) Problems of female sexuality: the defensive function of certain phantasies about the body International Journal of Psycho-Analysis 80: 645-660[]

Murray-Cox (1999) Remorse and Reparation London: Jessica Kingsley Neubauer, P.B. (1960) The one-parent child and his oedipal development Psychoanalytic Study of the Child 15: 286-309 [] Palmer, K. Oppenheimer, K. Dignon, K. Chaloner, K. Howells, K. (1990) Childhood sexual experiences with adults reported by women with eating disorders: an extended series British Journal of Psychiatry 156: 699-703 Plath, S. (1981) Daddy Sylvia Plath: Collected Poems London: Faber and Faber Rey, J. (1994) Universals of Psychoanalysis ed. Magagna,, J. London: Free Association Books Ritvo, S. (1976) From Adolescent to Woman Journal of the American Psychoanalytic Association 24: Suppl.127-137 [] Rosenfeld, H. (1987) Impasse and Interpretation London: Tavistock [] Schore, A.N. (1994) Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development Hillsdale, NJ: Lawrence Erlbaum Associates Shulman, I. Seiffge-Krenke, I. (1997) Fathers and Adolescents: Developmental and Clinical Perspectives London: Routledge Stein, A. (Producer) (1994) Formerly Anorectic Mothers and their Young Children. (Videotapes) London: Tavistock Clinic Symington, J. (1985) The establishment of female genitality Free Associations 1: 57-85 [] Tessman, L. (1989) Fathers and daughters: Early tones, later echoes Fathers and Their Families ed. Cath,, L. Gurwitt,, L. Gunsberg,, L. Hillsdale, NJ: The Analytic Press
- 79 -

Trowell, A. Etchegoyan, A. The Importance of Fathers Brunner-Routledge London 2002 Tustin, F. (1986) Autistic Barriers in Neurotic Patients London: Karnac Waddell, M. (1998) Inside Lives: Psychoanalysis and the Growth of the Personality London: Karnac Winnicott, D.W. (1964) From Paediatrics to Psychoanalysis London: Hogarth Press Wisdom, J.O. (1976) The role of the father in the mind of parents, in psychoanalytic theory and in the life of the infant International Journal of Psycho-Analysis 3: 231-239 []
- 80 -

Article Citation [Who Cited This?]

Magagna, J. and Pepper Goldsmith, T. (2009). Complications in the development of a female sexual identity. J. Child Psychother., 35:62-80