Eating disorders such as anorexia and bulimia have been hijackedby cultural studies academics and theorised to abstraction, argues Susie Orbach. Bingeing and vomiting are expressions of women's feelings about their bodies and food and not symbols of imagined sexual obsessions. Psychoanalysis must stop treating eating merely as a metaphorical activity

Freud's psychoanalysis was a sumptuous affair. The cases that he first wrote about in Studies on Hysteria are stories in which mysterious physical paralyses with no explicable organic basis are unravelled and treated, restoring to the patient enigmatically lost aspects of themselves.

It was Freud's great contribution to link an understanding of body and mind, psyche and soma and to insist, against the general current of 19th-century medicine, that hysteria was both a psychical and physical event. For Freud this was not just a theoretical proposition. Freud's great empathy for his patients led him to try to enter into their symptomatology: so that his interpretations, his understanding of the meaning of the symptom, the hysterical phenomenon, could come from an engagement with that hysteria.

After the second world war, psychoanalysis loses its sensual understanding. It becomes curiously dislocated from the body. Bodily distress, particularly sexual, is discussed, but in terms of symbols rather than through an engagement with what bodily states feel like and engender. Although analysts working with children capture in their writing something tactile and sensual about the relationship between psyche and soma, this is rare, and British and North American analysis rushes forward at a fast mentalist clip, subsuming physical symptoms into a schema where what is important to psychoanalysis are theories of the mind and the elevation of meaning and symbol at the expense of the body as the means of understanding patients.

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So how then has psychoanalysis dealt with a rush of symptoms that cluster around eating? Anorexia - the refusal to eat; bulimia - uncontrollable eating followed by purging; compulsive eating - eating without regard to physiological hunger? How has it addressed patients with eating problems?

To the detriment of many who suffer with such distress, psychoanalysis has tended to see the eating problem as subsidiary to, rather than centrally expressive of, the psychological life of the individual. It has either trivialised the problem or expected it to go away with the right doses of interpretation, directed not so much at the eating per se as at the problem the eating is assumed to disguise. Until recently, for example, a psychoanalytic reading of compulsive eating would call for the interpretation of unresolved oedipal feelings or would interpret anorexia nervosa as a refusal to accept female sexuality. Such interpretations lost much of their validity because they bypassed listening to the patient in favour of relying on a construct: the woman is fat therefore she wants the father's child. The woman is thin; she refuses a female rounded body therefore she is pre-oedipally arrested. Absurd and crude as such interpretations sound, they encapsulate the kind of understandings previously available.

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Part of the problem, of course, is that psychotherapists were unable to listen to a patient's despair about her eating, or her obsession about food and her body, without immediately translating the language of food and eating into something else, almost before it had been grappled with in its own terms. The vitality that informed Freud and the early psychoanalytic pioneers and which gave birth to the practice of interpreting the unconscious, has become both reified and ossified. Instead of interpretation being part of a process of understanding and engagement with the lived experience of the patients, it now became a thing, a set of a priori formulations handed to the patient that could leave her painfully marooned with her pain.

This diversion of the patient's experience around food as though it were only valid as a metaphor has intrigued me. It is as though the actuality of food and, by inference, the materiality of the body, flesh, digestion, evacuation and its processes are somehow unseemly - an unfit subject for analysis. Perhaps thinking about such processes engenders discomfort in the therapist. Perhaps entering into a dialogue about the eating practices of an individual is too private, more private than the revelation of a patient's sexual life. But perhaps above all, discourse about eating is often not engaged with by practitioners because of the pain it arouses in the analysand and analyst. Perhaps what is exposed is so excruciating, so pitiful that it becomes almost too much to bear. The eating or non-eating experiences of the patients and their manifold experiences of their bodies cannot be engaged with because, quite simply, it hurts too much. In place of engagement then, interpretation - which is really nothing more than a particular kind of conjecture - is substituted. The patient and her symptom is "read" as text; the body becomes an almost literary construction as opposed to the problematic place in which the individual lives and breathes.

Paradoxically, this reading of the patient's body as text or the reading of the symptoms of anorexia, bulimia or compulsive eating as symbol, was born out of work done in the 1970s by gender-conscious psychoanalytic clinicians engaging with patients who had eating problems. The rapid explosion of such problems spawned the dissemination of the understandings gathered from these patients' understandings whose rich and graphic meanings were so arresting that they soon entered the cultural landscape through books such as my own Fat is a Feminist Issue, published in 1978. It was not long before they then found their way into universities, where those in cultural studies playing with themes coalescing around gender, the body, disguise and revelation seized on them as a new literary form. Soon this academic theorising fed back into psychoanalysis itself, unwittingly further devaluing thinking about the patient's experience and instead reading the action of eating or not eating as entirely symbolic.

When I started work as a psychotherapist in the early 1970s, it became impossible to ignore the place of eating problems in the psychological life of many of the individuals, mainly women, that I was seeing. It was as though there was a secret epidemic eating at the bodies, hearts and minds of women of all ages. Indeed so unrecognised was this epidemic and yet so widespread that it was almost as though it was an aspect of being female. The women I was seeing took it for granted that they should be obsessed about their body size and distressed about their eating. It was simply a fact of life. Worse than that, they felt helpless in the face of such preoccupations, making talking about them in any depth, pointless. The only solution was to find a magical cure.

When, instead of concurring with such a stance, I paid attention to what they said about their eating and their bodies, it was as though I was listening to something between a code and a patois: a short-cut language used to explain something both intimate and social about how they conceived of their bodies, the meaning of food in their daily lives and a way to communicate about emotions. "I'm fat" was not simply a statement about body size and the relationship between adipose tissue and muscle. Rather I was to understand by it the myriad culturally endowed meanings of the term fat. I was not meant to question it, to ask the women (or myself) why or how they believed what they believed, I was not supposed to see the obsession with food as a way in which femininity is constructed in our culture, and I was not to understand it as anything but a negative judgement. Simultaneously I was supposed to know, without in any way drawing attention to it, that it stood for the expression of often profound emotional distress. "I'm fat" could never be accompanied by "I'm feeling good, content, well". It might mean, "I'm full of self-hate", it might mean "I'm miserable".

As a psychotherapist, I had the distinct feeling that to ask what "I'm fat" meant would be to breach something taken for granted, perhaps even to seem to expose an ignorance on my part that could engender distrust from the patient, indicating that I must be very weird not to understand such a simple declaration. On the other hand, disconcerting as I recognised such a question might be, I also thought it would be ultimately useful and potentially liberating. It might allow for a different kind of language, one other than the repetitive refrain of fat and thin, eating and not eating. It might allow women to express through words, rather than through concealed actions, something more direct about their experience.

In posing the question and refusing to accede to the negative aspect the statement "I'm fat" was expected to evoke, I realised I was up against a formidable taboo. It was as though I was asking the individual to reorientate themselves in some profound way.

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But being located in psychoanalysis, a discipline so used to deconstructing what it hears, I did ask and I did want to know what the individual meaning(s) of "I'm fat" could be and why the idiom of food and body size was so unquestioned and so powerful in the lives of the women I was seeing. To comprehend that, not just at the level of symbol, I needed to enter into the experience of food and of eating for the women troubled by it. I needed to know, smell, feel, connect with the texture of their eating and non-eating episodes: the binges and the purges, the evacuation of what had been taken in but could not be held inside.

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In her book Female Desire: Women's Sexuality Today, Ros Coward made the point that pictures of beautifully prepared food are like pornography for women. They show the finished product over which we slave and then long for (because women are too conflicted to eat in a straightforward manner) without recourse to the labour process that has created it.

I needed to go further than the details of the preparation of food, into the emotional distress that made the preparing of food for others one kind of act, while preparing food for oneself and ingesting it quite another. I also needed to understand why, what and how it felt for an individual to be gravitating towards food when not physically hungry or refusing it when starving. What is going on physically and psychically when this occurs?

Before interpretation could be of any value - beyond ensuring the cleverness of the therapist - it was imperative that the details of what an individual felt like before she started a binge, while she was eating compulsively, after she finished eating or conversely if she felt unable to eat, needed to emerge, to be held in front of us, not concealed, so that they could be, as-it-were, ruminated over and digested. In this way the physicality of the experience could be understood so that the divide between the psyche and the soma could be (temporarily) dissolved in the therapy. And, more significantly, the experience for the individual could become a lived rather than a split-off experience, one of which they could dare to be conscious rather than one of which, because of shame, self-disgust and dissociation, they had little awareness.

One of the achievements of psychotherapy is to make available to the individual the incorporation (by which is meant the taking into oneself both psychically and physically) of that which is a trouble to one but is elusive. Through the recognition of something that has been disregarded or split off, because of repression, shame or extreme hurt, the individual has the possibility to occupy a new psychic space. Thus it is with eating problems. By not being afraid to enter into the details of an individual's eating, by demonstrating that what may feel initially verboten for her - only possible of being enacted rather than held in mind and thought about - is not equally fearful to the therapist, the therapist is able to help the individual enter a conversation with herself about the eating, a conversation which has the possibility of enabling the individual to connect up with her symptom and in the course of time to make creative links between that which has previously been rendered as somatic.

By trying to enter into the experience with the individual, I am not so much trying to help her confront the ingestion or evaluation of large quantities of food; that interests me little, certainly at the level of censure. The job is rather to help us find a stance of curiosity and then acceptance towards the actions. With that established, even if it is hard for the individual to believe that she can develop an empathy towards what she regards as so shameful, we can then go on to recognise what the eating or not eating might be about. It is not that I am arguing that eating is devoid of the symbolic: how could it be? But a focus on the symbolic without recourse to engagement with the experience of food and eating, fullness and emptiness, cannot render the experience but symbolic. It can only lead an individual who suffers with an eating problem stranded in the symbolic or the prosaic - both positions are devoid of the texture of a lived experience, the very thing that is required to be restored to the individual if she is to have a life that is not defined by an eating problem.

As long as analysts and therapists accede to the statements of an individual about body size, food ingestion or food refusal without exploring them, they are leaving the patient in the pre-symbolic, rather as though the arm of Freud's patient, Anna O, were to remain paralysed. The experience of the arm would not be engaged with and the reincorporation of the arm into the body of the person as an arm, rather than as a symbol, would not be effected.

I would also argue that as long as those enamoured by cultural studies valorise the body as the place in which we solely inscribe and fail to understand the human pain, suffering and struggle involved in eating problems, we will simply have modernised our interpretations to fit in with 90s metaphors. More useful, I suggest is to use our understanding of eating problems and body preoccupations as a window into what is so troublesome for women today and to restore to psychoanalysis one of its more beautiful endeavours: the attempt to link our psychical and physical elements.

Susie Orbach is a psychotherapist and writer. She pioneered approaches to eating problems in her books Fat is a Feminist Issue and Hunger Strike.

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