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There has been remarkable consistency to what researchers and therapists have noticed about the personality characteristics of women with anorexia nervosa (Wonderlich, 1995). As discussed earlier, White 0983), writing about characteristics of women who develop anorexia nervosa, speaks of families who value sensitivity, loyalty, and self-sacrifice. Perfectionistic and compliant children are the most attentive to these family requirements. It seems likely that a gift who is valued for her helping function would develop into a woman who puts others' needs before her own. The characteristics of the women in this study that were more salient to the development of anorexia nervosa included compliance and perfectionism.
Compliance. Bruch (1985) noted that women with anorexia nervosa were unusually good and compliant children. Eight of the women spontaneously used the word "compliant" to describe themselves when they were young. For example, Josslyn (age 19) said, "I was always trying to please." Of the other 3 participants, 2 more stated that they always felt misunderstood as children; nevertheless, the words they used to describe their upbringing indicated a wish to be considered good. In relation to her mother, Meg (age 21) said, "I always went through this phase in which I would just tell her the truth about anything that happened if I thought it was bad." Only one woman in the study indicated that she was not very concerned with compliance. She stated that, as a child, she would "never take no for an answer" (Sarah, age 18). This woman was surrounded by an extended network of nurturing adults and, parenthetically, had the briefest experience for the women in this study with the full diagnosis of anorexia nervosa. Anorexia nervosa was how many of these women could distinguish themselves from the family system. Betty (age 24), thinking about her understanding of her mother, stated, "I felt she wanted us as children to behave or be in a certain way, like, she wanted us to be quiet or she wanted, like, for example, all of us had the same haircut .... I just didn't feel individualized in that sense." In trying to understand this experience, Betty felt that her feelings about the difference in expectation between her mother's Asian culture and her American upbringing led to her change from a compliant and quiet little girl to an acting-out adolescent. For three women, a period of adolescent acting out in gang participation, fighting, drug-taking, or stealing behavior preceded the development of anorexia nervosa but was not sustained as a way to accomplish the function of differentiation. In agreement with Bruch (1985), rebellion from a stance of compliance, seemed to coincide in most cases with the development of anorexia nervosa in the women in this study.
Perfectionism. In addition to being compliant, these women were also concerned with perfectionism. Many of the women discussed both their own and their families' desire for perfectionism. Several women felt pushed to succeed.
Nevertheless, for Karen, there was an obvious sense of conflict around this statement as she described how she had become ambitious. The internal voice pushing Karen to be a "perfectionist" seems to have come from an internalized parental desire. "Just everything about my dad, like how he pushed us to do things, really try hard and be active and not lazy, and I always find myself just, like, looking at other people who are lazy or who don't get into things like I always get into things, like I see that coming from my dad, like I'm really determined, very determined, sometimes too determined, like I see that coming from my dad, totally."
Linda (age 18) described herself as having no middle ground in regard to her schoolwork: "I don't know if being as ambitious as I am is a good thing or I don't know but, umm, it's definitely more positive than being, you know, apathetic." In regard to her eating, too, this woman has gone through periods of extreme food restriction and periods of constant bingeing on carbohydrates. The same dichotomous thinking style that led her to believe that taking a break, taking care of herself, would be tantamount to apathy led her to believe that she could either be "thin" or "fat." Jodie (age 21) described how her academic perfectionism led her to avoid new friendships because of her focus on academics. Her attention to schoolwork became at once a justification and an obstacle to attending to other important developmental needs.
That women with anorexia nervosa have a cognitive "black-and-white" understanding is important for a study of autonomy and connection. Where relational needs are defined as dependency, there is less room for women with anorexia nervosa to attend to both needs of autonomy and connection. Because the identity process for adolescent women involves self-differentiation within the context of relationships, healthy adolescent development requires an ability to look at the subtleties of relationship (Gilligan, 1982; Miller, 1991). The women in this study discussed dependence and independence as distinct categories, with little understanding of the need for integration as part of the process of development. When Teresa (age 21) was asked how she would describe herself, she answered, "Independent, ummm, very--or, at least, I try to be self-sufficient. Ummm, ummm, I don't know, I'm a perfectionist. A lot of people see me as really strong because I'm less emotional than a lot of people I know, yeah." The next question that the researcher asked, "So if you were going to tell yourself how you really are aside from how people see you, how would you do that?" elicited a very different answer. "How I am? Okay, then I am fragile. I don't think I have any coping skills." This woman had been struggling with depression and anxiety and had learned in therapy that she had relational needs. When queried, she automatically switched from seeing herself as autonomous and independent to seeing herself as completely dependent. The insight that she learned in therapy seemed to have been grafted on rather than integrated.
In listening to the narratives of women with anorexia nervosa, we saw that compliance and perfectionism were personality characteristics that both affected and were affected by the core category Social and Family Structures that Encourage Substituting Others' Needs for One's Own. Under the stress of the process of development, these young women were unable to negotiate the competing demands of attending to the development of both independence and relationships.
Reflection Exercise #3