Full of pain, starved of the right treatment: Forcing anorexia sufferers to eat may ease our anguish but does not help theirs, says Susie Orbach

WE HAVE a couple of stock phrases that surface in conversation when the subject of anorexia comes up: 'This is dieting gone wrong', or 'If only I could catch just a small dose of it'; but unless we have been personally touched by anorexia, when we are confronted with a young woman such as Samantha Kendall, who is starving herself, and who for 12 years has restricted her eating so that now she feels herself to be incapable of swallowing, we recoil.

Just as we know little about the meanings and prevalence of anorexia (an estimated 1 per cent of young British women between 14 and 23 are anorectic; about 150,000 die of it in the United States; the Department of Health here keeps no figures on it), so we know little about the available treatments.

Samantha and her now deceased twin sister Michaela are alleged to have endured refeeding, electro- shock therapy and psychiatry in the name of treatment during the 13 years of their joint 'slimming pact'. Samantha fears she cannot find the kind of help that will reach through to her in the UK. She's taking up an offer from Canada. I'm not surprised.

In-patient treatment in the UK, with few and notable exceptions, depends upon a behaviourist regime. The patient is confined to a hospital cubicle, isolated, stripped of personal belongings and access to a telephone, and denied a private visit to a bathroom lest she regurgitate the supervised, punitively calorie-rich meals she is forced to eat four times a day, until she has gained a target weight set by a doctor. She will be seen by a psychologist or psychotherapist once or twice a week whom she is supposed to trust, who is somehow miraculously split off from the brutalising rule surrounding her. Through this relationship of 'support' and by complying with the doctor's orders she is supposed to regain her weight, have her belongings and rights restored, adjust to more normative codes of femininity and step back into society.

There are many issues in the treatment of anorexia that stem from our lack of understanding of what it is and from our dis-ease with taking on the pain that we feel when we meet someone who is literally starving herself. Our discomfort may be such that we will wish to fight the anorectic, to stop her making us feel so uneasy by taking away from her the control she has fought so hard to exercise over her food intake. In forcing her to surrender, professionals relieve themselves of the burden of having to examine her pain and the discomfort her starvation induces in them. While the patient may eat and thus appear to comply during treatment, released, she will once again deny herself the food she needs, unless the underlying issues that have led to anorexia have been addressed.

Unwittingly, clinicians perpetuate the very problem that creates the response of anorexia inside of her. The woman feels unable to digest certain kinds of feelings. Her inability to speak of her pain, anger, confusions and distress has meant that she has to speak with her body rather than with her mouth about her agonies. If those agonies are then side-stepped, she has learnt that they can't be heard, they can't be spoken of, they mustn't be felt. Where she starved herself to starve out her difficult feelings, she is now being encouraged to stuff them down. She is not offered a chance to discover what is symbolised by her skeletal appearance.

In Samantha's case one can only guess at the horror of what she is now living through. The need to play out her conflict between life and death on a mid-Atlantic stage, her guilt, the fact of her survival and her twin's death, her rejection of what the UK has to offer and her hope that the New World can give her what she needs, suggest to me that her conflicts are even more excruciating than they are for most women whose anorexia is kept in secrecy, away from public eyes, hidden from friends and family until it can be concealed no more.

Samantha, by daring to call attention to her plight, is allowing us to review the provision of treatment here. She is suggesting that there is something desperately wrong with what she has been offered. What we haven't discovered is whether Samantha and Michaela were subject to the abusive and questionable treatment practices I've detailed (which seem to me to border on violating the civil rights of the person) or whether she and her sister were listened to. We may reasonably fear that those treating her have not gone beyond the worn-out platitudes I've read in the newspapers over the past 36 hours about anorexia - that it affects the middle class (only if you don't look for it elsewhere), that it is genetic (I'm intrigued to know just where it is on the DNA), that it is a refusal to be grown-up (without a discussion of why being a grown-up may have seemed difficult to Michaela and Samantha) and so on.

No wonder Samantha is intrigued by the offer of help from Canada. Canadian physicians and psychotherapists have worked to provide human and sensitive treatment for anorectics. Before we insist that she could have found adequate help here, let's review what we offer and have a public conversation about the kind of treatment we think is appropriate when women starve themselves.

The writer is author of 'Hunger Strike: The Anorectic's Struggle As A Metaphor For Our Age', Penguin, pounds 6.99. Her new book, 'What's Really Going On Here?', is published by Virago at pounds 7.99.

Copyright Susie Orbach 1994. All rights reserved