EATING DISORDERS

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THE CRUCIAL ROLE OF

PSYCHODYNAMIC
UNDERSTANDING IN THE
TREATMENT OF EATING
DISORDERS
Kathryn J. Zerbe, MD

Psychodynamic treatment of eating disorders centers on helping

patients understand the meaning of the manifest symptoms in context
to find ways to master maladaptive modes of coping and to improve
overall quality of life. Many men and women with problems of hinging,
disturbed body image, or curtailed eating remain ill even after an array
of cognitive, behavioral, pharmacologic, and nutritional interventions
have been used to alleviate their suffering.18 In these patients, the eating
disorder is often found to be the most overt or dramatic expression of a
complicated psychiatric picture. Psychodynamic interventions aim at
teasing apart the vast array of potential developmental antecedents of
the illness, including childhood and adult traumas, losses that have not
been fully mourned, the impact of parental misattunement, failed attempts at completing age-appropriate separation-individuation processes, and lack of affirmation of the self at crucial developmental
periods.12"17
Each individual has a unique personal history. Behind every symptom of disordered eating lies a story that is longing to be told. Clinicians
who use the psychodynamic method listen carefully to help these patients learn to process more effectively the distressing memories, disturbing feelings, and disrupted relationships (both childhood and adult-

From the Department of Psychiatry, Menrtinger Clinic; and the Topeka Institute for Psychoanalysis, Topeka, Kansas

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 24 NUMBER 2 JUNE 2001

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hood) that emerge during the recounting of these patients' life stories.
Because these patients' emotional pain is often experienced as difficult to
bear, the defense mechanisms of denial, splitting, dissociation, projective
identification, and repression are adaptively used by the mind to (temporarily) sidestep internal anguish. The first step in treatment, therefore,
must be the creation of a safe haven where these patients gradually
grow more comfortable in sharing aspects of the self that have stymied
personal growth and found general expression in the symptoms of the
eating disorder.
CONTAINMENT AND LISTENING
Psychodynamically oriented clinicians conceptualize this initial process of psychotherapy as containment.2'3 In lectures for therapists, the
author uses a slide of an ancient, hand-woven Indian basket to illustrate
that the first, and often primary, task of therapy lies in "being a good
enough container" for these patients' anguish, hopes, and dreams. Metaphorically speaking, these patients deposit into the basket their raw
affects, vignettes of personal history, deepest questions about the meaning and direction of life, and reactions to everyday dilemmas in personal
relationships. This initial psychodynamic intervention does not negate
the use of other treatment modalities, such as restoring adequate weight
and maintaining good nutrition, teaching these patients about the cultural and biological roots of their illness, and judiciously using cognitivebehavioral strategies to gainsay maladaptive patterns of coping (e.g.,
having the patient involved in a "relapse-prevention group" immediately after a meal to discourage vomiting at a high-risk time while
encouraging socialization, or helping the patient circumvent catastrophic
thinking if he or she relapses).
Rather, the process of containment is an additional but essential
intervention ultimately aimed at assisting these patients to gain respect
for themselves, their lives, and their struggles. Slowly, these patients
begin to link aspects of their stories togetheras if they were beads on
a silk threadand an enlivening sense of continuity or connectedness
about their lives takes shape for the first time. One's personal history
begins to make sense and be meaningful. These patients grow in their
capacity to take themselves more seriously, and in so doing, they discover the courage and curiosity needed to make the commitment to face
life; as a deeper understanding and appreciation of the self takes form,
these individuals can initiate making those life-affirming decisions that
abet their facing down the eating disorder.
Participants in seminars or students of psychotherapy sometimes
laugh when reminded of the late psychoanalyst Winicott's10-11 words of
wisdom to novice psychotherapists: "The first order of business is to
stay awake and alive during the therapy process!" Why did Winnicott
stress this point? Treating patients with eating disorders is illustrative of
a more general predicament in establishing a therapeutic alliance with

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any patient from a psychodynamic perspective. Hearing patients share

their stories is difficult work! It is far easier to write a prescription or
suggest some activities or daily drills than to actually attend to another
person's imbroglio.
When therapists listen carefully, they cannot avoid being drawn
into the emotions, conflicts, and confusions of the person. Sometimes
clinicians even find themselves cast into particular roles that feel odd or
uncomfortable. Notice the word person, not patient, is used. This deliberate choice of words underscores how, in any human relationship, that
carries with it intensity, intimacy, and the capacity to be swept away
with feeling, an inevitable counterpoint to avoid, to retreat, or to close
oneself off (as if in a cocoon) concomitantly occurs. Since the dawn of
human history, the battle of the sexes has largely been waged along
these lines; one sex blames the other for "not understanding" or "not
really listening." So it is not psychoanalysts who have discovered this
fundamental problem in human nature. Psychoanalysts have simply
made a study of why it becomes so hard to listento take another
person's woes and joys and discoveries seriously.

THE "PROBLEM" OF CONTAINMENT: CLINICAL USES

OF PROJECTIVE IDENTIFICATION
The dilemma aroused by attending to another person's affects
(which are initially unspoken and often unconsciously held) is primary
in the treatment of persons with severe eating disorders. By the process
of projective identification, therapists absorb the feelings of patients. For
example, at the beginning of a session, a therapist feels energetic, receptive, and eager to hear about whatever the patient has on his or her
mind. Approximately 20 minutes into the session, the therapist may
notice a change to feelings of discouragement or boredom and may have
to prod him- or herself out of a growing sense of disengagement and
sleepiness. At the end of the session, the patient may leave the office
not having said much directly about any one particular reaction or
experience. But the therapist may find him- or herself irritable, even
angry, and growing frustrated if a patient has not appeared to make
much concrete progress or use the session well.
What has happened here? The treater has absorbed the (usually
unconscious) mood or affective state of the patient. Because the patient
and the therapist were unaware during the session that a prevailing
affect was subconscious, they could not talk about it. The feeling was not
put into words and, thus, went unmetabolized. But in psychodynamic
psychotherapy, to paraphrase Scarlett O'Hara, "tomorrow really is another day." The therapist remembers, then inquires, about the previous
session. One might even make some educated guesses or interpretations
to the patient about what might have been going on in the previous
session. Gradually, the therapist doses back the feeling or feelings that

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were successfully contained by the therapist in the previous sessions so

the patient can process them.
When patients have a better sense of the hidden affects they have
been harboring and can link these feelings to important memories,
conflicts, and interpersonal situations with words, they have a much
better capacity of managing crises without turning to their eating disorders. Naming feelings helps patients gain a sense of mastery over themselves and have a more effective adaptive repertoire of behaviors to use
when encountering life's demands. But the process begins with an
unnamed or unknown feeling that was "deposited" in raw form into
the treater that, with time, can be understood. In this example, the
treater used psychodynamic theory to settle back and reflect on what
was happening in the session. He or she hypothesized that, by projective
identification, he or she was experiencing a split-off or unknown part of
the patient, and when this feeling or experience was made discussible,
both participants learned something about what was going on that
previously had been invisible and unknowable to both of them. In
essence, the goal was to follow the psychoanalytic dictum "to make the
unconscious conscious" to enlarge the reflective capacities of the patient.
When this is done, patients are less likely to use maladaptive means
(e.g., their eating disorders) because they have achieved new capacities
to make use of their minds constructively
Often in the treatment of eating disorders, patients "identify with
the aggressor" and treat their therapists as they were treated in childhood.4 In these situations, patients may express intense frustration, rage,
and even loving or erotic feelings toward the treater. This is especially
true when there is a history of significant physical, sexual, or psychosocial trauma. Containment becomes the primary therapeutic strategy,
with therapists silently processing as these patients verbalize their emotional states. With sufficient time, therapists can interpret how these
patients have pathologically identified with the person(s) who hurt
them, and these patients can make a new and more salutary identification with their therapists.
In essence, abnormal object relationships are replaced over time
with healthier ones, but this is easier said than done because the affects
expressed and the elements of personal history told can be so riveting
that therapists may wonder what can constructively be done to help
these patients. Some treaters become emotionally or sexually involved
when importuned by patients for physical comfort. This abrogation of
the professional boundaries arises when therapists have acted out an
abnormal object relationship and missed the opportunity to help these
patients understand the tendencies to act destructively toward themselves. When containment fails, eating-disordered patient also miss opportunities to learn more adaptive methods of self-soothing and to make
essential differentiations between feelings (e.g., love and hate, affection
and sexuality, envy and admiration) that promote personal growth.
When intense anger is expressed, there is a need to conceptualize
this dynamic further. The treater is being placed in the role of the "bad

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object." In these situations, one assumes that these patients have a need
to defeat or devalue their clinicians based on early trauma or maladaptive family patterns.12-13 Therapists must feel comfortable with setting
limits when these patients express rage; firm boundaries are a cornerstone for treatment because these patients learn from them to test out
and to affirm thier own personal and body boundaries. Interpretations
of the source of the anger can be made over time but can be used
effectively only if a patient is ready to hear. Timing is key. Premature
interpretation usually fuels additional hostility because it repeats an
earlier developmental pattern: No one would listen or safely diffuse or
contain the rage. The capacity and willingness for therapists to assume
the role of "bad object" is challenging but enables these patients to
perform more effectively in the outside world and to curtail symptoms
because aggression is mobilized and channeled more adaptively.
Experienced therapists have often observed that they may feel that
they are "doing nothing" or "always feeling dumped on and devalued"
only to hear from external sources that these patients have decreased
their purging, started eating, or performed better at school or on the job.
By helping these patients manage powerful affects using containment,
the feelings become ultimately less terrifying, therapeutic needs are met,
and these patients "signal" growth by what happens in their "real"
lives. They may not be able to thank their therapists directly or ever
completely stop their symptomatic behaviors, but their progress is exemplified by their elaboration of their stories in session and the personal
development that occurs outside of sessions. Gradually, these patients
shift from the defensive mode of "identification with the aggressor," in
which projection was the only way to dislodge their pain to a more
adaptive, mature mode of communicating various feelings and ego
states. They internalize from their therapists new ways of working with
feelings, memories, disappointments, and successes.

DEVELOPMENTAL INTERVENTIONS BASED ON

ATTACHMENT THEORY
Emerging data from the fields of cognitive neuroscience and attachment theory support theoretic notions about how to intervene with
persons with severe psychological difficulties, including eating disorders. In a review of 763 pediatric analytic cases at the Anna Freud
Center in London, Fonagy and Target6 found that children who grew up
in severely traumatic environments had better opportunities for quality
of life and resilience after the trauma if they had the capacity for primary
reflective functioning. Developmental interventions aimed at verbalizing
internal states, breaking down anxiety into small entities, increasing the
capacity to think clearly, separating reality from fantasy, and delaying
gratification were modifications of "classic" analytic technique that
proved essential in helping the children lift inhibitions on mental functioning that in turn made access to the "mental world easier and, in

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extreme cases, possible for the first time." Although the treatment required considerable time, these children made considerable gains in
their capacity to think about cause and effect, create representations of
themselves and others, establish reciprocity in relationships, develop the
capacity to delay gratification, and be able to hold opposing ideas in
their minds. In essence, they markedly improved over the course of the
psychodynamic therapy despite the significant psychopathology they
had brought to the treatment.
In contemporary psychodynamic psychotherapy and psychoanalysis, lessons learned from this kind of research helps clinicians to appreciate more fully why interventions may have therapeutic power. Psychodynamic interventions can be further conceptualized as providing the
space for these patients' primary reflective functions to grow and expand, thereby giving these patients the opportunity to make "dramatic
revisions of internal working models of relationships."8 Eating-disordered patients who are aided to construct a life narrative in therapy
may likewise be getting a "second chance" to thrive. Detailed case
reports from the analytic literature 5 - 9 - 12 - 1S - 16 attest to this, but surely
more research must be done to confirm how sensitive caregivers may
compensate for risk factors such as early maladaptive relationships in
families. Nonetheless, psychodynamic interventions help these patients
to become "aware of the intentional stance in themselves and others
during discrete episodes of interaction"8 that may ameliorate pathologic
antecedents of behavior, such as earlier patterns of physical or psychological neglect, temperamental difficulties, and parental psychopatholgyWORKING WITH TRANSFERENCE: THE DIALECTIC
OF AUTONOMY AND CONNECTION
Pivotal in the psychodynamic work of patients with eating disorders
is an understanding of the transference and countertransference patterns
that inevitably emerge as the work proceeds. Because strong feelings are
likely to arise on the part of both parties in the treatment dyad, ongoing
supervision (i.e., space for the therapist to process those issues that are
inevitably stirred) is highly recommended.
Case Example
An 18-year-old patient with a 6-year history of anorexia told her therapist
repeatedly about her parents' marital discord and her mother's loneliness. There
was no history of physical or sexual trauma, but the patient believed that she
had "to take care of [her] mother" because her father was seldom at home, her
parents fought intensely when they were together, and her mother "had no
friends and was so depressed."
The patient's difficulties began when she had the opportunity to join school

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activities that took her away from her mother for hours over the weekends. The
patient's mother was not overtly destructive, but the patient felt guilty about
participating in age-appropriate activities because "[her] mother wanted [her] to
stay home, watch TV with her, and go shopping."
In the therapy process, the patient would closely observe her therapist for
any waning of interest when activities, school, and friendships were mentioned.
The therapist pointed out that the patient seemed to stay on guard to "figure out
what [the therapist] might want [the patient] to do." The therapist's sensitivity to
the maternal transference issues enabled the clinician to gently wonder and
later confront the patient for not permitting herself more participation in ageappropriate activities. The therapist observed how anxious the patient became
when she did much of anything for herself and how this might be related to
her need to stay close to her mother and to not take age-appropriate steps
toward separation while still being connected in a more age-appropriate way to
her mother.4-7
In this case, understanding how the patient was attempting to repeat in the
transference an earlier, but ultimately unhealthy, way of relating enabled the
eating symptoms to subside. The patient did not have to "find [her] own space"
by not eating, nor did she have to "stay a little girl" because this is what she
assumed adults (e.g., her mother and her therapist) desired. Individual therapy
and family sessions were necessary in helping the patient's mother find satisfaction with her daughter that did not stymie the patient's growth. But that aspect
of the treatment plan was formed by experiencing and understanding what the
patient brought in terms of her own fears about growth and development as
they were repeated, interpreted, and worked through in the transference.

Such patients have a need to experience "growth in connection" 7

but concomitantly must discover what psychoanalyst Balint called the
"friendly expanses" 1 of the world. Eating-disordered patients speak with
pride about the control they have over their own bodies by vomiting at
will, exercising for hours, and avoiding eating despite being ravenous.
This notion of personal autonomy is fictitious and destructive.
To rechannel their need for control in a positive direction, treaters
and family members must champion newfound abilities and the acquisition of skills "to stand alone" and to take in "true perspective . . .
and proper proportions." 1 Psychodynamic interventions clarify the intrapsychic conflict (and to some extent, existential dilemma) of discovering
friendly expanses and venturing out into the other-than-eating-disordered world while enjoying satisfying interpersonal connections.
Healthy relationships provide a sense of security and well-being without
a need to cling or be clung to. Therapists make use of emerging trarisferential patterns to point out to these patients when the swing is too much
in one direction or the other based on these patients' experience of an
earlier relationship and the here-and-now relationship to their therapist.
Such therapists must be attentive to issues of "optimal distance" and
make use of opportunities such as vacations, relapses after poignant
sessions, and interruptions or other changes in the therapist's "real" life
to engage in discussions about the dialectic needs for closeness and
autonomy.

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SUMMARY
Psychodynamic interventions for eating-disordered patients can
provide a unique pathway to understanding the illness. Contemporary
practice strives to integrate insights derived from drive theory ego
psychology, object relations, self-psychology, relational and attachment
theories, and intersubjectivity to claim a more thorough understanding
of the antecedents of the eating-disorder symptoms. Placing emphasis
on the unique personal history of the individual and finding a safe
haven in which to process that history are cornerstones of psychodynamic treatment embraced by each of these schools of thought.
This article has emphasized the importance of creating a safe space
for these patients to speak, processing the most salient affects that arise
in the therapeutic dyad, assessing potential transference and countertransference paradigms, and assisting these patients in mastering symptomatic behaviors by making healthier identifications with their therapists. Although the selected topics merely sketch how psychodynamic
treatment may apply in some cases, it is hoped that they will whet
the appetite for a more sustained inquiry for readers. Contemporary
psychoanalysis aims to be more "user-friendly" for patients and treaters
and eschews a "one interpretation fits all" approach to any person
suffering from a particular diagnosis. Attachment theory, infant and
developmental studies, and in-depth outcomes research are shaping the
way that psychoanalytically informed treatments are carried out. Within
the next decade, insights derived from these kinds of psychoanalytic
research will be even more concretely and meaningfully used in the
treatment of eating disorders and other Axis I conditions.

References
1. Balint M: Thrills and Regressions. New York, International Universities Press, 1959
2. Bion WR: Learning from experience. In Seven Servants: Four Works by Wilfred R. Ben.
New York, Aronson, 1977
3. Bion WR: Brazilian lectures 2. Rio de Janeiro, Image Editora, 1974, pp 1-105
4. Casement PH: Learning from the Patient. New York, Guilford Press, 1985
5. Farrell EM: Lost for Words: The Psychoanalysis of Anorexia and Bulimia. London,
Process Press, 1995
6. Fonagy P, Target M: Predictors of outcome in child psychoanalysis: A retrospective of
763 case at the Anna Freud Centre. J Am Psychoanal Assoc 44:27-78, 1996
7. Jordan JV, Kaplan AG, Miller JB, et al: Women's Growth in Connection: Writings from
the Stone Center. New York, Guilford Press, 1991
8. Stein H, Fonagy P, Ferguson K, et al: Lives through time: An ideographic approach to
the study of resilience. Bull Menninger Clin 64:281-305, 2000
9. Wilson CP, Hogan CC, Mintz IL: Psychodynamic Technique in the Treatment of the
Eating Disorders. Northvale, NJ, Jason Aronson, 1992
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Hagarth Press, 1965
11. Winnicott DW: Human Nature. London, Free Association Books, 1988
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DC, American Psychiatric Press, 1993

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13. Zerbe KJ: Whose body is it anyway? Understanding and treating psychosomatic
aspects of eating disorders. Bull Menninger Clin 57:161-177, 1993
14. Zerbe KJ: Selves that starve and suffocate: The continuum of eating disorders and
dissociative phenomena. Bull Menninger Clin 57:319-327, 1993
15. Zerbe KJ: Integrating feminist and psychodynamic principles in the treatment of an
eating disorder patient: Implications for using countertransference responses. Bull
Menninger Clin 59:160-176, 1995
16. Zerbe KJ: Feminist psychodynamic psychotherapy of eating disorders: Theoretic integration informing clinical practice. Psychiatr Clin North Am 19:811-827, 1996
17. Zerbe KJ: Knowable secrets: Transference and countertransference manifestation in
' eating disordered patients. In Vandereyken W, Beumont PJ (eds): Treating Eating
Disorders. London, Athlone Press, 1998, pp 30-55
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disorders. In Petrucelli J, Stuart C (eds): Hungers and Compulsions: Contemporary
Perspectives in the Psychoanalytic Treatment of Eating Disorders and Addictions. New
York, Aronson, in press
Address reprint requests to
Kathryn J. Zerbe, M D
Menninger Clinic
5800 SW 6th Avenue, Box 829
Topeka, KS 66601
e-mail: zerbekj@menninger.edu