Table Of ContentWORKING WITH EATING
DISORDERS
A Psychoanalytic Approach
Geraldine Shipton
BASIC TEXTS IN COUNSELLING
AND PSYCHOTHERAPY
Series editor:Stephen Frosh
This series introduces readers to the theory and practice of counselling and psychotherapy
across a wide range of topic areas.The books will appeal to anyone wishing to use
counselling and psychotherapeutic skills and are particularly relevant to workers in health,
education,social work and related settings.The books are unusual in being rooted in
psychodynamic and systemic ideas,yet being written at an accessible,readable and
introductory level.Each text offers theoretical background and guidance for practice,with
creative use of clinical examples.
Published
Jenny Altschuler
WORKING WITH CHRONIC ILLNESS
Bill Barnes,Sheila Ernst and Keith Hyde
AN INTRODUCTION TO GROUPWORK
Stephen Briggs
WORKING WITH ADOLESCENTS
Alex Coren
SHORT-TERM PSYCHOTHERAPY
Emilia Dowling and Gill Gorell Barnes
WORKING WITH CHILDREN AND PARENTS THROUGH SEPARATION AND DIVORCE
Loretta Franklin
AN INTRODUCTION TO WORKPLACE COUNSELLING
Gill Gorell Barnes
FAMILY THERAPY IN CHANGING TIMES – 2e
Sally Hodges
COUNSELLING ADULTS WITH LEARNING DISABILITIES
Ravi Rana
COUNSELLING STUDENTS
Geraldine Shipton
WORKING WITH EATING DISORDERS
Tricia Scott
INTEGRATIVE PSYCHOTHERAPY IN HEALTH CARE
Paul Terry
COUNSELLING THE ELDERLY AND THEIR CARERS
Jan Wiener and Mannie Sher
COUNSELLING AND PSYCHOTHERAPY IN PRIMARY HEALTH CARE
Shula Wilson
DISABILITY,COUNSELLING AND PSYCHOTHERAPY
Laurence Spurling
AN INTRODUCTION TO PSYCHODYNAMIC COUNSELLING
Invitation to authors
The Series Editor welcomes proposals for new books within the Basic Texts in Counselling and
Psychotherapy series.These should be sent to Stephen Frosh at the School of Psychology,
Birkbeck College,Malet Street,London,WCIE 7HX (email [email protected]).
Basic Texts in Counselling and Psychotherapy
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W
ORKING WITH
E
ATING
D
ISORDERS
A Psychoanalytic
Approach
G S
ERALDINE HIPTON
© Geraldine Shipton 2004
All rights reserved.No reproduction,copy or transmission of this
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C
ONTENTS
Acknowledgements viii
1 Introduction 1
The incidence of eating disorders 2
Eating disorders as an end-point for different 3
pathological processes
Children with eating disorders 4
Men with eating disorders 4
Moving in a psychoanalytic direction 5
Who is this book for? 6
The structure of the book 7
2 The Cultural Context of Eating Disorders 10
Ashort history of eating 11
Some feminist perspectives on eating disorders 12
Anorexia’s special attraction 14
Eating disorders and self-management 15
Body practices and embodiment 16
Globalisation: views from mainstream clinicians 19
3 Anorexia Nervosa 25
Early psychoanalytic contributions to 26
understanding anorexia
Anorexia as a defence against bulimic desires 29
‘Second-skin’ function 30
Dimensionality 31
Clinical illustrations 32
Jenny: the psychotherapy of an anorexic 32
When therapy breaks down 41
Susan: short-term therapy 44
V
CONTENTS
4 Bulimia Nervosa 47
The psychodynamics of bulimia 49
Contemporary perspectives 51
Borderline personality disorder 54
Michael: a boy who never stopped running 56
(a failed brief engagement with a group)
Ellen: a four-year, once-a-week therapy 58
Discussion 67
5 Obesity 69
Psychotherapeutic encounters with patients 71
who are obese
The psychodynamics of obesity 74
Amy: an introduction to a clinical case 78
Discussion 87
6 Issues for the Practitioner 90
Introduction 90
Assessment 90
Management and liaison 93
Technique 95
Transference, countertransference and the 99
analytic attitude
What is in the transfer to the therapist 100
Hate in the countertransference 102
Body image 105
Men with eating disorders: gender identity 107
and body image
Supervision 109
7 Concluding Thoughts 111
Psychic retreats 112
Psychotic parts of the mind 113
Symbolic equations 115
Negation 116
Mental space 116
Psychosomatic disorders 118
Irritable bowel syndrome (IBS) 119
Self-harm 120
Sexual abuse 122
Self-help 123
Families and friends 123
vi
CONTENTS
Life-style choice 124
Research 124
Cultural contexts revisited 125
Additional Information 129
References 130
Index 140
vii
A
CKNOWLEDGEMENTS
I would like to thank all those people who have trusted me with
accounts of their own eating difficulties and struggles with self-
esteem and self-image. I hope I have used the privilege with due care
and respect. I am especially grateful to Gianna Williams and
members of the eating disorders workshop at the Adolescent Unit of
the Tavistock Clinic. I have also learned a lot from all those partici-
pants who came on short courses in Sheffield or those who have
spared time to talk to me since, such as Sandra Thomas. Em Farrell’s
contributions to the course as a seminar leader greatly aided my
understanding of bulimia, in particular and made working together
fun. Many others have contributed to the development of my under-
standing in different ways at different times. I thank Dr Anderson,
DrBirksted-Breen and Dr Sedlak for what they have taught me about
psychoanalysis. I am grateful to Professor Ron Akehurst for study
leave from the University of Sheffield and to Trudy Coldwell for her
secretarial assistance. Finally, I thank AKB for his unstinting and
essential support!
viii
1
I
NTRODUCTION
Eating disorders are one of the most common forms of mental health
problem and are associated with increased risk to life. Over the
last 30 years they have become more finely differentiated so that
nowadays we talk of anorexia nervosa, bulimia nervosa, binge-
eating, sub-acute eating disorders, eating disorders not otherwise
specified (EDNOS) or may refer to obesity and self-starvation. We no
longer believe anorexics are not hungry or that they are only ever
young, white, middle-class females. Indeed, we are very well
informed about eating disorders: our magazines and newspapers are
full of information about the dangers of eating disorders and fasci-
nated by the body-size of celebrities and the diets to which they sub-
scribe. Obesity has become a major priority for governments across
the world and according to the World Health Organisation is ‘the
single biggest European public health challenge of the 21st century’
(Wallop, 2003) and may necessitate taxing fatty and sugary foods.
Diets are big business, the fast food industry even bigger, and
increasingly, so is litigation. Obese people have begun to sue food
companies and retailers such as McDonalds for apparently making
them obese. Eating disorders bring together the private and the pub-
lic in a very profitable way. And furthermore, we all know what it
feels like to question whether or not we are eating ‘properly’ or look
‘right’.
Eating is an activity that involves the external and the internal
world. Menzies summed this up as: ‘One may truly say people never
eat alone or uninfluenced by others, since they always eat in the con-
text of the “internal society”’ (Menzies, 1970: 223). This internal soci-
ety is made up of the relationships we experienced when young but
further external influences cannot be avoided whether we wish them
to be or not and we are all subject to external judgement about what
are acceptable or unacceptable ways of dealing with our earlier
feeding experiences. Menzies reminds us of a scene from one of the
1
