Abstract
This book consists of a collection of papers with an extensive introduction by the editors (appearing in each volume), who explain the title relates to the struggle of some patients to accept another and to become dependent on another, but also to ‘the need of clinicians to accept generously the sometimes violent projection of their patients’ and describes the flow of giving and receiving between patient and clinician.
The authors are current and past members of the Tavistock Eating Disorders Workshop, the Adolescent Department of the Tavistock clinic in London and clinicians in Italy who had completed the Tavistock model courses.
In their introduction, the editors state that central to the psychoanalytic thinking behind the cases is a perspective principally defined by Melanie Klein's theory of object relations. The focus of the first volume is on early childhood and relates to the reversal of the early dyadic relationship between mother and infant. In the second volume in the adolescent cases, the focus is on failure to work through the oedipal situation.
Chapter 1 recounts a 2 years' observation of an infant with a very disturbed feeding relationship with her mother, who seemed to focus her own relationship to her infant on breast feeding. Her infant appeared to view her mother's persistent offer of the breasts with entrenched contempt.
The second chapter describes two cases of early feeding difficulties illustrating that early feeding problems may evoke maternal anxiety which then impairs the feeding experience leading to food refusal. These feeding difficulties are explained on a psychoanalytic basis and may be relevant to those dealing with nonorganic feeding problems of early childhood, and to view the problems in the context of family relationships.
The third chapter gives an account of a 5 years old boy with constipation, soiling and refusal to eat and associated social difficulties. The extensive interpretation resulting from 11/2 years of weekly sessions would interest those with a psychoanalytical approach, but might provide little help for those other clinicians who are so often confronted with this problem.
Other chapters include a description of 3 years' therapy for a boy whose restricted food intake was interpreted as a manifestation of a defence against anxiety. There is also an interesting account of aspects of body image in a 6 years old autistic boy who experienced eating as a dangerous function.
A chapter is devoted to describing therapy for a boy with persistent vomiting since early childhood and with an inability to eat, coming from a dysfunctional family. At school he exhibited an ability to express himself first in drawing and later in very articulate writing. What was of greatest interest to this reviewer was the central and positive role of his teachers (the authors) in resolving this boy's disabling problem.
In the second volume, the eight chapters address aspects of severe eating disorders in adolescence through case studies. These include an account of an anorexic girl of 14 with the typical features of excessive exercise and altered eating, discussing interpretation of her behaviour that emerged during thrice weekly sessions over a year. A further study describes a 16 anorexic girl torn emotionally between fear of dying and fear of becoming fat. Much of therapy, addressing her intense feelings, focused on interpretation of her dreams.
A study of a 17 years old bulimic girl described the psychotherapy with considerable focus on her family. The extensive and helpful discussion addresses the question – why does bulimic behaviour become a primary symptom for some individuals and their families, and not for others? It points out the importance to differentiate epidemic peer group fad bingeing/purging (most of whom do not go onto true bulimia), from post anorectic bingeing/purging, and the smaller number who go onto develop true bulimia.
In the fourth chapter the author describes a two phase therapeutic intervention in a 17 years old girl who was treated in hospital. After a year the patient discontinued therapy, but later resumed after overdosing. The therapist describes her own distress during the period she was treating this girl. Another chapter describes a 17 years old girl who had been admitted in coma requiring resuscitation. She was described as suffering from ‘Pervasive refusal syndrome’, an extreme example of the profound helplessness and hopelessness underlying many severe eating disorders, requiring very intensive psychotherapy. The author further elaborates on nine other children with this disorder she had treated.
Other chapters include one entitled ‘Some reflections on the processes of projection and introjection in eating disorders’ and describes a 19 years old bulimic who underwent 3 years of analysis. A description in another chapter describes a 19 years old anorexic girl with depression and discusses the relationship between intense feelings and eating.
For whom is this book written? Clearly not for most clinicians struggling with the care of so many children with feeding problems, or the adolescent physician addressing eating disorders, though it does give insight into a psychoanalytical approach. It is addressed to those psychotherapists who provide ongoing therapy to patients who are at the severe end of the wide spectrum of eating disorders. It provides insights into the psychoanalytical approach, but the treatment is extended in duration and intensive in professional resources.
The book does not address the question of how the outcome of this approach, and the expenditure of professional time, compares with other forms of treatment for a condition of young people that is becoming increasingly prevalent in Western society.