Anorexia Nervosa is a most puzzling and perplexing phenomenon to try to understand. If you are a woman in the midst of an anorexic phase, you are probably as confused by what is happening to you as everybody else is. Even those of you who have recovered from anorexia and have left it far behind might still find it hard to give an account of what it is all about.

To women who have not experienced anorexia themselves, the whole thing might at first appear to be quite outside their range, of understanding. There is a temptation to try to make sense of anorexia as though it were an illness, totally alien to the experience of 'normal' women. Those women who are or have been anorexic will know how frightening and alienating it feels to try to explain to another woman how you feel, only to be met with blank incomprehension, or worse, to be treated as though you are mad. And yet it is only when we begin to approach the problem as an extension of the difficulties which all women have in our lives, that we can really begin to make sense of the experience itself, and of the issues which underlie it.

Since many people who work with anorexic women have not themselves had the experience of anorexia, for them, understanding presents its own special problems. I say this with some conviction, for I have spent a good number of years trying to understand. To some extent this book stands as a record of my attempts.

I first met a woman in an acutely anorexic phase something approaching a decade ago. I can remember the occasion well although I had no means of knowing at the time that this was an important landmark in my professional life. I was a psychiatric social worker, she an in-patient in the unit in which I worked. I hadn't long been qualified and my training had encouraged me to interpret my role as being in some way 'different' from, 'other' than the 'patients' with whom I worked. Indeed, most of the clients with whom I worked were very different from me. I had all the advantages in life while they had very few. Their symptoms were the expressions of the bad deals, either materially or emotionally, which life sometimes hands out. As far as understanding went, it was not usually hard to see why they sat where they sat and why I sat where I did.

Then Sandra came into my office and into my world. I had seen her before in ward meetings and found her something of an enigma there. She was not a 'difficult' patient (yet). On the contrary, she was clearly very caring and perceptive. A rather lovely young woman who hid her natural charm to some extent under a kind of mousiness. Apart from being thin, she looked quite ordinary.

I knew about anorexia of course. When I was at school, some girls I did not know 'got it'. People said it was the influence of Twiggy. Today perhaps Kate Moss would be held responsible. The girls left hurriedly and I always thought they must really have wanted to be fashion models. Sandra seemed rather a serious person and did not look at all as though she wanted to be one...

She came in and we chatted for a while. Quite a long while, I suspect. How old was she? Just a few years younger than myself, as it turned out. In terms of her recent past, it transpired that she had graduated from a neighbouring university to my own in a similar combination of subjects. We talked about poetry a bit, and about painting. She really got me thinking about Van Gogh. She was in fact a very engaging person and, for once, it was not too clear to me why she was 'the patient'.

She had gone to university with mixed feelings. Her family had its problems and when she had left them, she was feeling rather guilty about pursuing her own self-development and leaving them to manage without her. I could understand that. I did not say much about myself, then or ever I think, but it was quite clear to me at the time that I was identifying with Sandra and that I was quickly getting to like her.

I thought I ought to begin to explore the issue which had brought us together. I invited her to tell me about the difficulties she had with food and her weight. The change in her manner was dramatic. She looked frightened, talked fast. She did not know why she felt as she did, but the feelings were more powerful than anything she had ever felt before. Food was obviously utterly terrifying. She still felt, at her pitifully low weight, that she was too fat. She could acknowledge that she was 'wrong' and that quite probably she ought to gain some weight, yet the thought was repulsive to her. This, I thought, is madness. Yet it was not a mad woman I was speaking to. Until five minutes ago, before we got on to the subject of weight, I had thought of Sandra as the kind of person I would probably enjoy talking to at a party. Now this other, incomprehensible Sandra. I could not believe it. People had told me that 'anorexics' were really quite unreasonable. But she was not, except about her body and the way she nourished it.

In this short and superficial account of what must have been a rather short and superficial interview is contained the rationale for much of what subsequently took place, not only between Sandra and myself, but in my increasing interest in the problem of anorexia.

Gradually I began to learn more about Sandra. I began to see her as someone who found life difficult in a more general way than I had realised. What struck me in particular was her huge and immovable sense of guilt. She thought of herself as mean and selfish, which she certainly was not. Anything she did, unless it entailed ultimate self sacrifices, would be evidence of her utter uselessness. She experienced herself as a parasite, a worthless thing with nothing to give to anyone. My protestations to the contrary were of no use at all. She heard me talking of grace, but she knew she was not among the chosen. Yet she continued to cover this profound sense of worthlessness with a weary and sometimes even cheerful commitment to doing the right thing, to getting better and to finding a means of being 'useful'.

The problem for me was that I could find nothing within myself which would help me to understand what Sandra was saying to me.

The first breakthrough in my understanding came when I was trying (so far in vain) to relate her difficulties about food and eating to her rather over-developed moral sense. Overcome with frustration and with wanting her to begin to see herself as I saw her, I found myself raising my voice and squeaking, 'But eating's not a moral issue!' (If I'd had a table to hand, I would probably have thumped on it.) She looked at me, slightly amused, somewhat superior, and said, "Well - it is.'

I do not know what happened next, but I could not forget what she had said. She was right, of course, it is!

I began to understand from my own experience what it was she had meant. Greed and self-indulgence, our own or other people's, offends us in a moral way. Think of the feeling after Christmas when everyone has spent three or four days (or more if we are lucky) engaging in persistent self-indulgence. We feel spoiled by our own greed; spoiled not just in a physical sense, which may or may not be important to us, but spoiled in a moral sense too. Our immediate response is to take up running, to go and play a few games of squash to 'work it off'. This reaction is not simply a remedy for our bodies, but the physical hardship and endurance applies salve to the soul as well. We behave as though the body is indeed the mirror of the soul. Fat people, simply by virtue of their shape and size, seem to be telling us that they are careless, indolent, lacking in self-control and even in sensitivity. We know this is not true, but we behave as though it is. Sandra, by cruelly manipulating her body into the perfect ideal of thinness, was trying to say all the opposite things about herself. I had discovered that she was an ascetic. And more importantly, that these were feelings which I and other people were able to understand.

My experiences with Sandra also made me think about the attitudes of so-called 'normal' women to food and to our bodies. I began to realise that the behaviour of most.of us is, in a real sense, quite strange. Most of us are not regarded as having illnesses, and yet to call our attitudes to food, to eating and to our bodies 'normal' is to make an unusual use of the word. We do not just eat: we slim, we worry, we weight watch. We also spend an inordinate amount of time absorbed in the business of food: feeding others as well or instead of ourselves, shopping, cooking and clearing up the waste. The chapter which follows is an attempt to clarify my thinking about.this, to try to get beyond the idea that anorexia is simply slimming gone mad, and to document the disordered set of relationships which women have with and around food.

By this time, I had started to read books about anorexia. Most of them left me more confused than I had been before. I was starting to get a steady trickle of new referrals of anorexic women. The books did not seem to answer any of the questions I was beginning to formulate. The women I was meeting were all interesting, thoughtful and intelligent. Why should this particular group of women, suddenly, out of the blue, as it always seemed, develop such a deadly preoccupation with their bodies and their weight? What was happening to these women which did not happen to others, which gave them such a precarious sense of who they were? Surely all women are subject to the same social pressures to be slim and to have bodies which people approve of? Why did some of the brightest and best of us need to express distress in such dramatic and self-defeating ways?

Feminist literature at the time seemed to concentrate on women's failures. The focus seemed to be on why women did not do well in education, why we failed to achieve. And yet so many of the women I was meeting had done or were doing very well at school and were successful in their own right. Chapter 3 represents my attempts to discover the answers to some of these questions.

Meanwhile, Sandra continued not to get better. She was discharged, readmitted and discharged again. She lived on a knife edge. She did not know how to eat and she did not know how to live. She described her feelings about food as 'like being in a state of continual civil war'. It always seemed to me that she was in a state of siege, but unlike most besieged people, the armies which surrounded her were attempting to feed rather than to starve her.

At about that time, I met Janet, a woman in her early 30s. She described to me one day how she would spend her lunch hours walking from one cake shop to another, looking in the windows, smelling the newly baked bread, thinking about the possibilities of going in and buying something, but hever venturing over the threshold. That image of the starving woman, confronted with abundance, but unable to nourish herself at all, impressed me deeply. I did not know how to understand it, but I could not forget it. I have since discovered it to be a very familiar story and one which many women will recognise.

Then there was Sarah. She would sit in sleeveless clothes by an open window in mid-winter until she went blue. I myself hate being cold almost more than anything else and I remember feeling so sorry that someone felt they had to endure it, day after miserable day. Yet Sarah was striving to overcome her human nature, which she felt to be weakness. I have since learnt to recognise this too as a compulsion which many women share.

Gradually it began to dawn on me that these women seemed to endure, even seek out physical sensations like cold and hunger simply so that they could overcome them. The important thing was the sense of power and control which this overcoming brought with it. The frame began to widen. If the need to subdue and take control of the body was so great, then surely an underlying issue must be a sense of lack of control in other areas of life.

Here again it was possible to understand - the life difficulties of women with anorexia in exactly the same ways as we can understand the difficulties which all women encounter in our lives.

Anorexia affects a very fundamental area of all human experience and concern: the relationship between ourselves and our bodies, between us and what we eat. And other people's reactions to anorexia seem to confirm the idea that it touches on themes common to us all. Most people are very interested in it. A common reaction among women when it is mentioned is: 'I wish I could catch it for a while' or 'I could do with a dose of that'. This indicates, I think, that many women are aware that the area of their lives concerning food and their own size and shape is not altogether a happy one.