Transference and countertransference of eating disorders

ings
to their treatment relationships: Th ey both fear domination and long for
soothing and empathy (Zerbie, 1998). Th ey also bring high levels of aggression,
as refl ected in the destructiveness and persistence of their symptoms. In
psychodynamic terms, strong transference and countertransference reactions
are to be expected and, many believe, are necessary for change to occur.
Transference
Th e Value of Symptoms Patients oft en highly value anorectic symptoms.
Feelings of mastery and distinction, derived from the ability to fast, counteract
feelings of worthlessness. As one student said, “Whenever I walk into
a room, I immediately determine who is the skinniest. When it’s me, I feel
great. When it’s not, I feel so insecure I can barely talk.” Obsessions with
food and weight, though tormenting, can be easier to contend with than the complexities and threats of interpersonal relationships. Patients’ experience
is also fairly predictable, which appeals to those who are otherwise
easily overwhelmed. Th eir thoughts and routines are repetitive, and their
emotional range is narrow. Although individuals with bulimia and BED
tend to be more ashamed than anorectics, they do value the regulatory function
of their symptoms. Th ese individuals are prone to extremes in impulse
and mood, wavering between states of boredom and intensity. Bingeing and
purging temporarily replace boredom, numbness, or stress with stimulation
and focus, and moderate the edges of intense experiences by relieving bodily
tension (Goodsitt, 1983).
Th e psychological payoff of symptoms oft en makes for power struggles in
the therapeutic relationship; clients fear clinicians want to take away what
gives them self-defi nition and regulation. Th e challenge for clinicians is to
acknowledge the purpose served by the symptoms while simultaneously helping
clients fi nd identity and modulation in ways that do not damage the body
and diminish vitality.
Ambivalence Eating disorder symptoms help students manage distress by
providing distraction and illusory feelings of control. Yet they also isolate
students into an existence of obsessive and ritualistic self-involvement. Sufferers
are thus strongly and ambivalently attached to their symptoms. Th ey
feel both devoted to and tormented by them.
Letting go of symptoms entails disengaging from an internal relationship
with them that has served protective psychological functions and that has
come to determine moods, thoughts, and actions. Doing so involves internal
upheaval and giving up the reinforcing aspects of the disorders.
Ambivalence about getting better oft en manifests in treatment as artifi
cial compliance, dishonesty, or attacks against clinicians. To pull clients
out of their symptoms, clinicians need to off er a treatment relationship that
is compelling and hopeful enough to compete with clients’ attachments
to their disorders (Davis, 1991). When students begin to feel nourished by
their therapist’s empathy and acceptance, they can disengage from their
symptoms.
Rage Eating disorders are associated with high levels of anger and anger
suppression (Waller et al., 2003). Individuals with eating disorders are oft en
perfectionists who believe that their anger is unacceptable (Siegel, Brisman,
& Weinshel, 1988). In confl ict about an emotion they have in abundance,
they turn to the body for help. Fasting blunts interpersonal responsiveness
and, in so doing, contains anger. Bingeing and purging dull feeling and lower
arousal.
In the treatment with eating disordered individuals, anger is oft en cloaked.
Th ese clients tend to be outwardly compliant and pleasing, while subverting attempts at progress (Goldner, Birmingham, & Smye, 1997). Th e clinician’s
challenge is to halt the acting out of anger through eating disorder symptoms
and to invite direct expressions of anger into the therapy. Open expressions of
negative transference signal progress in treatment.
Countertransference
Feeling Ineff ective Th e refractory nature of eating disorders oft en leaves
clinicians doubting their best eff orts and training. It is helpful to remember
that feelings of inadequacy are at the core of eating disorders (Bruch, 1962).
Moreover, individuals with eating disorders are uncomfortable with their
feelings and are adept at obscuring them.
It behooves clinicians who feel ineff ectual to consider what clients are
playing out with them. Clinicians who fi nd themselves beset with feelings
of ineff ectiveness may be resonating with their clients’ experience. Clients
may also be sabotaging therapeutic interventions to avoid feeling controlled
(Zerbie, 1998).
Rage Based on past experiences, individuals with eating disorders have
come to believe that their anger, if expressed directly, will provoke retaliation
or abandonment. To preserve attachments, they have rerouted anger into
their bodies through eating disorder symptoms. Aggression toward others
does seep out, but oft en unwittingly and obliquely.
When therapists allow expression of clients’ hostility in the therapy relationship,
they help redirect clients’ anger away from themselves and their
bodies. But being the target of clients’ aggressive feelings is diffi cult, especially
if the anger is built up and unmodulated. Clinicians may fi nd themselves
counterattacking by disengaging, being silently punishing, or off ering
critical interpretations. Th e therapeutic challenge is to receive and contain
clients’ anger without shutting down or retaliating. Th is is not to say that clinicians
need to masochistically absorb clients’ hostility; rather, the role of the
clinician is to help clients own and, ultimately, modulate and constructively
communicate anger. Clinicians who are able to do so send clients the corrective
message that all aspects of them, including rage, are knowable and tolerable
(Zerbie, 1998).
For example, one client snapped at her therapist for being “too analytical”
whenever the therapist asked questions designed to tap into feelings. Th e therapist
felt belittled and slipped into quiet passivity. When the therapist was able
to avow and use her own anger to inform inquiries about and resonate with
the student’s rage, the treatment gained momentum. She said to the client,
“I can imagine you might feel threatened and defensive when I ask you pointed
questions, given how intolerant and shaming your parents were of your feelings,
especially your vulnerable ones. You protect yourself by letting me know
to back off , like when you tell me I’m too analytical.”

Fear Eating disorders are stubborn illnesses with high rates of recidivism
and grave medical risks. Many of those affl icted with the disorders, moreover,
are attached to their symptoms and in denial about their severity.
Clinicians must bear and process anxiety for their eating disorder clients,
who are defi cient at both gauging and regulating their own emotion. Oft en,
therapists fi nd themselves worried and preoccupied about students who
appear calm and unconcerned even as they participate in dangerous behaviors.
Fear needs to be fed back to clients in doses they can tolerate and use. Too
much fear triggers panic and urgency, while too little colludes with denial. A
therapist might say, for example, “Th e treatment team is concerned about your
recent drop in weight. You have several weeks to demonstrate to yourself and
to us that you’re healthy enough to be at college at this time. Specifi cally, this
means you’ll need to adhere to your meal plan and regain the weight that you
lost. If you can’t, we’ll have to heed your symptoms and recognize that you
need more help and support than you can get while being a full-time student.”
Being clear and objective about the required changes helps relieve the therapist
and shift s the anxiety and the need for change back onto the student.
Working as part of a treatment team ensures that the fears and responsibilities
that accompany this work are shared. Continual supervision also lets
clinicians discharge and distill overwhelming anxieties.