affect regulation, object relations and the central symptoms of eating disorders

European Eating Disorders ReviewEur. Eat. Disorders Rev. 14, 203–211 (2006)

Affect Regulation, Object Relationsand the Central Symptoms ofEating Disorders

David Clinton*Resource Centre for Eating Disorders, Karolinska Institutet, KarolinskaUniversity Hospital—Huddinge, Stockholm, Sweden

The ‘over-investment of eating restraint’ is arguably an importantcommon denominator of eating disorders. The present paperexplores this characteristic from the perspective of developmentalpsychology. Recent advances in the integration of psychoanalytictheory and empirical research on infancy, can extend our emergingmultifactiorial understanding of eating disorders, and help usto better understand the development and maintenance of thiscentral symptom. It is proposed that the over-investment of eatingrestraint typical of eating disorders may reflect an underlying needto restrict affective experience in general, and the experience ofdesire in particular. The clinical implications of these ideas areexplored, especially in regard to how the therapist helps thepatient to discriminate, integrate and express inner feeling-states.It is concluded that interdisciplinary work can help us to furtherextend our understanding of eating disorders. Copyright # 2006John Wiley & Sons, Ltd and Eating Disorders Association.

INTRODUCTION

Patients who suffer from eating disorders are hetero-geneous in terms of background, diagnostic fea-tures, comorbidity and personality functioning.Eating disorders typically occur in adolescent andyoung adult females, but are not uncommon in per-sons of considerably older and even younger age.Most, but by no means all, patients will initiallydevelop a restricting form of eating disorder, andmany of these will go on to develop binge-eating.Depression and/or anxiety disorder can be seriousproblems for many eating disorder patients at somepoint in their lives (Bulik, 2002). Marked histories ofimpulsivity and/or substance abuse are to be foundamong some patients, while others show no traces ofsuch problems (Holderness, Brooks-Gunn, & Warren,

1994; Nagata, Kawarada, Kiriike, & Iketani, 2000).Personality functioning in general (Walsh & Garner,1997) and levels of ego functioning in particular(Norring et al., 1989) can vary considerably. Esti-mates of personality disturbance in eating disordershave been reported to range between 23 and 93 percent of cases (Rosenvinge, Martinussen, & Ostensen,2000). Diagnostically, even with regard to clinicalsymptoms, the picture is so varied that perhaps 30to 60 per cent of all eating disorder patients may failto meet criteria for the two central syndromes ofanorexia nervosa and bulimia nervosa and are thusclassified as Eating Disorder not Otherwise Speci-fied (EDNOS) (Fairburn & Walsh, 2002).

The clinical diversity of eating disorders is mir-rored in our emerging theoretical understandingof their complex aetiology. Most experts wouldagree that one perspective alone does not suffice toexplain the origin and maintenance of eating disor-ders. As the Maudsley group have expressed it ‘wecannot focus exclusively on psyche or soma, butmust pay close attention to a complex interactionbetween the two’ (Ward, Tiller, Treasure, & Russell,

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online 26 June 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.710

* Correspondence to: David Clinton, M.A., M.App.Sci., Ph.D,Resource Centre for Eating Disorders, Karolinska Institutet,Karolinska University Hospital—Huddinge, M57, S-141 86Stockholm, Sweden. Tel: þ46 8 58585796. Fax: þ46 8 58585785.E-mail: [email protected]

2000). We now see eating disorders in a multifactor-ial perspective, where biological, social and psycho-logical factors act together to predispose, trigger andmaintain patients’ problems. The important aetiolo-gical questions, therefore, no longer concernwhether eating disorders are caused by biological,social or psychological factors, but rather how suchfactors interact over time to produce the diverse phe-nomena we meet in clinical practice.

What I wish to do in this paper is to explore ques-tions related to the defining common features of eat-ing disorders and how we might better understandthe development and maintenance of these centralsymptoms over time. I will contend that the coresymptom of eating disorders is what has beentermed ‘eating restraint that is over-invested’. I willthen go on to explore this symptom in a develop-mental psychological context, focusing on factorsthat may contribute to the predisposition for andmaintain of eating disorders. More specifically, Iwill draw on recent developments in theories ofaffect regulation, empirical infant research andobject relations theory. I will contend that the over-investment of eating restraint typical of eating disor-ders may reflect an underlying need to restrict affec-tive experience in general and the experience ofdesire in particular. I will also contend that theover-investment of eating restraint typical of eatingdisorders may reflect an unconscious need to repeatand resolve earlier dysfunctional interpersonal rela-tionships. This line of thought can complementour emerging multifactorial understanding of eatingdisorders, as well as aid clinical work and stimulateresearch. It also offers a means of integrating ourgrowing knowledge of eating disorders withadvances in other areas of science.

THE OVER-INVESTMENT OFEATING RESTRAINT

There is currently much debate about the classifica-tion of eating disorders (Clinton, Norring, Button,& Palmer, 2004). Although the relevant questionsare far from being resolved, there is a growing inter-est in distinguishing a core of central symptoms com-mon to specific eating disorders and distinct fromother psychiatric disorders. This is partly born ofclinical necessity and the need to focus treatmentstrategies on meaningful goals that transcend speci-fic eating disorder diagnoses (c.f. Fairburn, Cooper,& Shafran, 2003). It is also born of the anomalies ofEDNOS. The fact that this large group of patientscan be considered eating disordered, without fulfill-

ing full criteria for the two major syndromes, begs thequestion of what constitutes the common denomina-tors of eating disorders. Surprisingly, this questionhas received relatively little attention in the empiricalliterature. Recently, however, Fairburn and Walsh(2002) have defined an eating disorder as ‘a persis-tent disturbance of eating behaviour or behaviourintended to control weight, which significantlyimpairs physical health or psychosocial functioning’.

Although being a clear step forward, the definitionFairburn and Walsh propose does have problems.They place emphasis on ‘behaviour intended to con-trol weight’. In a polemic on the hazards of unduefocus on weight concern as a general defining criter-ion for eating disorders, Palmer (1993) made someimportant observations that may be relevant to Fair-burn and Walsh’s proposed definition. He observedthat although ‘weight concern’ has clear applicabil-ity to the diagnosis of anorexia nervosa and bulimianervosa, it does have some important problems as ageneral criterion. Much the same can be said of‘behaviour intended to control weight’. As Palmerpointed out, the early 19th Century accounts of anor-exia nervosa did not emphasise, or even mention,weight concern. Moreover, cases of anorexia ner-vosa presenting in non-Western cultures are notknown for the salience of weight concern. Thereare also clear examples of patients (usually classifiedas EDNOS) who otherwise appear to have classiceating disorders, but who lack weight concern.

Despite Fairburn and Walsh emphasising beha-viour to control rather than concern about weight, theymay still be missing the central diagnostic issue. Andthat issue may have to do more with eating thanweight. In his polemic, Palmer drew attention towhat he called ‘eating restraint that is over-invested’. Amongst other things, he argued that eat-ing restriction (or attempts at eating restriction)appears to be a universal finding in the histories ofpatients presenting for treatment of an eating disor-der. It is obviously typical of patients presentingwith anorexia nervosa. It is also a characteristic ofthe disorganised cycles of binge-eating and compen-satory behaviour typical of bulimia nervosa. Even inpatients with binge-eating disorder, where there is alack of the behavioural manifestations of eatingrestraint, there will usually be found an emotionallyladen issue around the desire to control and restricteating, along with a history of failed attempts to doso. As Palmer points out, in the absence of appetiteloss attempted restraint tends to be opposed byincreases in the urge to eat. Moreover, Palmer arguesthat persistence of restraint in the face of regulatoryforces tends to increase these forces. As a result a

204 D. Clinton

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 203–211 (2006)

vicious circle may develop if fear of the loss of con-trol in the face of regulatory forces leads to anincrease and persistence of restriction. Althoughthe diagnostic issue of eating restraint versus weightconcern awaits further research, we can discerngrounds for viewing eating restraint that is over-invested as forming a common core symptom charac-teristic of the two major eating disorder syndromes,and, by and large, the vast majority of those patientsthat we now classify as EDNOS.

A QUESTION OF DEVELOPMENT

But what might motivate the over-investment of eat-ing restraint? Why might a person need to over-invest eating restraint? How might such a needarise? As Dare and Crowther (1995) have pointedout, the risk of embracing eating disorder symptomsis largely determined by social, cultural, familial,biological and cognitive factors. However, this isonly part of the matter. It is also important to under-stand an individual’s need for a symptom. By sodoing we can come to appreciate some of the impor-tant factors that make it so difficult to relinquishsymptoms. Such a need for eating disorder symp-toms can be best grasped in terms of what Dareand Crowther term ‘the developmentally under-standable psychological qualities of the person’.

At a conscious level, we can discern a plethora ofmotivators that we regularly meet in clinical prac-tice. For example, anorexics will commonly main-tain that they restrict their eating in order to avoidweight gain. Bulimics may express a need for greatercontrol over disorganised eating habits. Otherpatients may focus on the need to purify themselves,talk about peer pressure or espouse commonly heldcultural values about slimness. Such factors help usto understand important risks and pressures thatcontribute to the development of symptoms. How-ever, although these factors may play a necessarypart in the aetiology of eating disorders, I wouldargue that they fail to sufficiently explain the devel-opment of the marked over-investment of eatingrestraint typical of eating disorders. Besides beingleft with the question of why these symptomsdevelop in some individuals and not others, we arealso left with the question of why such psychologicalcharacteristics are so resistant to change. There canbe compelling rational reasons for changing one’seating behaviour, and not uncommonly patientsare able to initiate changes with the help of therapy.However, risk of relapse can be high and whenchanges are made they are often behavioural in nat-

ure, while underlying psychological manifestationsof the over-investment of eating restraint remainstubbornly resistant.

In order to better illuminate questions about theorigins of the over-investment of eating restraint Iwould now like to draw on recent developments intheories of affect regulation, empirical infantresearch and object relations theory. Here I willexplore the idea that the over-investment of eatingrestraint typical of eating disorders may have animportant unconscious basis. This may reflect anunderlying need to restrict affective experience ingeneral and the experience of desire in particular.To explore these ideas we need to start withrecent advances in the integration of developmentalpsychology and psychoanalytic theory.

Affect Regulation and Infancy

Not so long ago, infants were conceived of as passivebeings surrounded by a stimulus barrier that limitedexperience of the external world (e.g. Mahler, Pine,& Bergman, 1975). Now the emerging consensusis that infants enter life with a rich perceptual appa-ratus that is pre-wired to attend to and explore theexternal world, and which starts to build representa-tions of the external world on the basis of that experi-ence from the very beginning. For some relevantreviews of important research see, for example,Emde, (1988), Gergely (1992) or Stern (1985). A fun-damental aspect of this growing empirical knowl-edge of early development has been the discoveryof the infant’s sensitivity to contingencies betweenthe infant’s own actions and the perceived effectsthese have in the world around. These contingenciescan be seen as collections of expectations, similar to‘if–then’ conditional statements. A classic examplewas given by Watson (1972). He found that 2-monthold infants increase their rate of leg kicking when thekicking results in a contingent event (in Watson’sstudy the movement of a mobile above the infant’sbed). However, this will not happen when theinfants experience a similar but non-contingentevent. The implication is that detection of causal con-trol over the mobile’s movements is rewarding andstimulating in its own right. Other examples pertain-ing directly to interpersonal aspects of behaviourconcern studies involving the still-face procedure(Tronick, Als, Adamson, Wise, & Brazelton, 1978)or delayed feedback techniques (Murray &Trevarthen, 1985). In these experimental situationsof face-to-face interaction between infants and theirmothers, expected interpersonal contingencies aredisrupted. The interpersonal exchange does not take

Affect Regulation, Object Relations and Central Symptoms of Eating Disorders 205


place as the infant would expect, and considerabledistress can be observed in the infants.

Of relevance to the understanding of eating disor-ders and the regulation of affect is the work ofFonagy, Gergely, Jurist, & Target (2002). They presenta social biofeedback theory of parental affect-mirror-ing, and discuss the way in which the infant’s auto-matic expression of emotion, together with thecaregiver’s consequent affect-reflective facial andvocal reactions, comes to be linked in the infant’smind through the detection of interpersonal contin-gencies that gradually become internalised. The for-ging of such contingency links is thought to havetwo important effects: (1) infants come to associatethe control they have over their parents’ mirroringbehaviour with a resulting improvement in theiremotional state, leading, eventually, to an experienceof the self as a regulating agent; and (2) the basis foraffect regulation and impulse control is establishedthrough second order representations of feeling-states. As a result, affects can be manipulated anddischarged internally, as well as through action.Even more importantly, affects can be experiencedas something recognizable and shareable. Expres-sions of affect by the parent that are not contingenton the infant’s affect will tend to undermine theappropriate labelling of internal states, which mayremain confusing, unsymbolised and difficult toregulate.

The Fonagy group further develop their ideas inrelation to the pathological pathways that affect-mirroring can take. They argue that the emergenceof specific interpersonal contingencies during earlydevelopment create predisposing factors for theemergence of psychopathology later on. In particu-lar, they identify two main types of pathological con-tingencies. Essential to defining these contingenciesis their notion of ‘markedness’. Markedness con-cerns a response to the infant that allows the infantto identify the caregiver’s reaction as ‘not real’, i.e.the reaction is not an indication of what the caregiveractually feels, but rather an indication of what theinfant is feeling. Putting it another way, markednessrefers to interpersonal cues that allow the infant to‘tag’ or ‘mark’ a caregiver’s expressions as being arepresentation of something. This subtle quality ofinterpersonal interactions can perhaps be moreeasily recognised in the pretend play of children.Imagine, for example, a child who is pretending tohave stomach ache. Exaggerated intonation andfacial expression, together with stereotyped move-ments, high-pitched voice and knowing expres-sions, combine to convey that the child ispretending to have stomach ache. The participating

playmate or adult, knows that the expressed affect isnot conveying a real sense of physical discomfort.

The first type of pathological contingency dis-cussed by Fonagy and colleagues is associated withborderline personality disorder, and receives con-siderable attention in their work. It is thought to arisewhen a caregiver is overwhelmed by negative affectgenerated in response to the infant, resulting in care-giver reactions that lack markedness. The idea is thatif the caregiver displays an overly realistic emotion-ally arousing reaction (i.e. one that that lacks mark-edness), then the infant will be led to believe that thereaction is an indication of how the caregiver actu-ally feels. The caregiver’s reaction will not be per-ceived as a representation of something else. This,in turn, is thought to undermine, not only theinfant’s possibility of creating a secondary represen-tation of his/her inner state, but also the sense ofboundary between infant and caregiver. As Fonagyand co-workers put it, when a caregiver’s reactionlacks markedness the infant’s ‘internal experiencesuddenly becomes external through the experienceequivalent to contagion’. The second type of patho-logical mirroring, which receives less systematicattention, is thought to predispose to the develop-ment of narcissistic disorders. When affect-mirroring is appropriately ‘marked’, but is non-con-tingent (i.e. the infant’s emotion is misperceived bythe caregiver), the infant is thought to experience thecaregiver’s mirroring as mapping onto his/her pri-mary emotional state. However, since the mirroredstate is incongruent with the infant’s actual feelings,the secondary representation will tend to be dis-torted. The infant will, thus, mislabel the primaryemotional state and representations of the self willnot have strong ties to the underlying emotionalstate. Consequently, the infant may convey animpression of reality, but since the primary affectivestate has not been recognised (or attuned to) by thecaregiver, the self will feel empty and lack secondaryrepresentations of affect.

Affect Regulation and Eating Disorders

These ideas may be of relevance to better under-standing factors that may predispose to the over-investment of eating restraint. Generally speaking,the ideas of the Fonagy group can help us to under-stand how the naturally occurring internal processof affect regulation can break down, leaving anindividual without the means of appropriately iden-tifying and acting on internal feeling-states. Manyclinicians will certainly recognise problems thatpatients have with identifying and expressing

206 D. Clinton


affects in eating disorders. It may be that early diffi-culties in the regulation and mentalisation of innerstates result in a need to restrict and control theexperience of affect generally. The idea being that ifan individual cannot differentiate the inner feelingstates that are stimulated in a particular interpersonalexchange, he/she will need to restrict experience ofaffects generally in order to avoid being over-whelmed by diffuse feelings that cannot be identifiedor understood. The idea of problems with affect reg-ulation being involved in the origins of eating disor-ders is not new. Take, for example, the work on eatingdisorders and alexythymia, or Bruch’s (1973) theoriesabout the development of anorexia nervosa, whichfocused, amongst other things, on the role of how amother perceives and responds to her infant’s signals.More recently, Dare and Crowther (1995) as well asMcDougall (2001), have also drawn attention to therelationship between eating disorders and the regula-tion of unpleasant and undifferentiated affect.

Nevertheless, although we can envisage how diffi-culties in the regulation and mentalisation of affectduring early development might put a person at riskfor developing psychiatric symptoms generally,it remains unclear how such difficulties might contri-bute to the development of eating disordersspecifically. Are there particular interpersonal con-tingencies that might predispose toward an over-investment of eating restraint? On the one hand, itis entirely possible that there are, in fact, none. Itmay be that problems of affect regulation in general,when combined with other factors (e.g. societal, bio-logical vulnerability, family dynamics, etc.), areentirely sufficient to create a tendency for an indivi-dual to over-invest eating restraint during laterdevelopment. On the other hand, it is difficult tosee how these factors could combine to produce theresilient and overwhelming need to restrict eating,without the presence of some sort of specific factorthat could predispose to the salience of this symp-tom. It may, therefore, be fruitful to consider identi-fying particular sorts of contingencies that mighthelp to make eating restraint so appealing.

One possibility is that affect mirroring that takesdeviant pathways in relation to the experience ofdesire may have a particular bearing on the propen-sity to over-invest eating restraint. The role of desireis not dealt with explicitly by the Fonagy group.They seem to see the concept as similar to, yet clearlydistinct from, affect. However, the experience andregulation of desires may well be governed by simi-lar interpersonal contingencies during early devel-opment. We can use the models of borderlineand narcissistic psychopathology that the Fonagy

group develops as a point of departure. Applyingthe borderline model we might speculate thatwhen an infant desires something that the caregiveraccurately perceives and reacts to, but withoutappropriate markedness, the infant will succeed inadequately labelling the desire. But at the same time,it will be difficult for the infant to distinguish whosedesire is being experienced. Such a sense of confu-sion implies a lack of boundaries between self andother, and might predispose to a tendency to focuson the desires of others. Applying the narcissisticmodel we might speculate that when the infantdesires something, and the caregiver responds withappropriate markedness, but non-contingently (i.e.in relation to a different desire that the caregiver per-ceives), the infant may perceive the desire as his/herown, but mislabel it.

A complicating factor for this model concerns thenature of desire itself. Desire is something that isexperienced in relation to something else. It has anobject. What’s more, the object of desire can be saidto have both psychological and physiologicalaspects. For example, in a threatening situation thatcauses the infant intense discomfort, the infant maydesire both a physiological soothing function and apsychological interactive function. As such, a parti-cular manner of interacting with the caregiver maybe desired in order to achieve a reduction in a parti-cular state of physiological arousal. Putting itanother way, the infant may desire both soothingand someone who soothes. Problems may developif the caregiver is unable to distinguish betweenthe two functions. For example, if the caregiveraccurately perceives the physiological aspect ofdesire (e.g. need for soothing), but misperceivesthe psychological aspect of desire (e.g. relates in anon-congruent fashion). Such an instance mightarise when a mother accurately perceives herinfant’s distress, but attempts to soothe the infantby offering food or distracting the infant, rather thanby comforting and showing appropriate holdingbehaviour. The use of food or distraction mayreduce the displeasurable physiological state, butwithout the appropriate comforting and holding.The absence of this relational response may under-mine the development of a self-soothing mechan-ism, and make the infant more dependent on thesort of response that is available (e.g. the use of foodor distraction).

Object Relations

Ideas about the development of affect regulativefunctions raise questions of how the infant represents



internally the person who is responding to theinfant. Here psychoanalytic theories of object rela-tions may be of help. Roots of this school can befound in the writings of Klein (1975) and Fairbairn(1952), while contemporary applications in rela-tion to eating disorders have been described byLawrence (2001). According to object relations the-ory, a person’s psychology is not merely a functionof the interpersonal relationships that arise betweenindividuals in the external world, but also a func-tion of the intrapersonal relations that exist withinthe internal world of subjective experience. Boththese internal and external worlds are seen to beengaged in reciprocal interaction, where experi-ences of relationships in the external world arethought to influence the structuring of experience,and where internalised structures provide themeans of interpreting external reality. Simply put,one of the key ideas within this school of thought isthat objects in the outside world (e.g. parents,aspects of parents, etc.) become internalised as‘inner objects’. In the context of the presentdiscussion, the infant is thought to graduallyinternalise images of the actions of the caregiver,which come to guide patterns of experiencing andrelating. What this implies, amongst other things, isthat the sorts of interpersonal contingencies thatFonagy and co-workers discuss may also haveimplications for the fate of the caregiver withinthe infant’s inner world. As regards the questionof the regulation of desire, as discussed above, wemight conjecture that a caregiver who tends torespond to the infant’s expressions of desire with-out appropriate markedness or non-contingently,will tend to become internalised accordingly. As aresult the infant may come to expect others tobehave in a similar fashion.

If it is important what happens with the psycho-logical aspects of desire, it may be equally impor-tant what happens with the physiological aspects.If an infant or young child finds it difficult to differ-entiate internal states, and is not sure what he/sheis experiencing, then the detection of hunger andthe regulation of eating may become difficult.What’s more, a person who has early in life experi-enced a non-contingent form of affect mirroring,may find it problematic to distinguish betweenthe psychological and physiological aspects ofdesire. Discriminating sensations of hunger andexperiencing the desire to eat may thereforebecome particularly demanding, since such experi-ences may also symbolically awaken a deepambivalent desire in relation to the caregiver, whoin a sense promised to, but failed to, help the patient

develop sufficient regulatory mechanisms to dealwith the patient’s emotional experiences. Physiolo-gical processes such as hunger may, therefore,symbolically remind the patient of a painful psy-chological reality that must be controlled in orderto avoid being overwhelmed. The result may be atendency to over-invest eating restraint in orderto help keep such feelings at bay. On the one hand,the patient is reminded of the desire for a goodobject, i.e. a caregiver who is attuned to what isgoing on inside the infant, and who can providefor the psychological and relational aspects ofdesire. On the other hand, the patient is remindedof the reality of a bad object, i.e. a caregiver whofailed to satisfy desire in a congruent manner.

TREATMENT ISSUES

The over-investment of eating restraint has a num-ber of implications for treatment. Being a cardinalsymptom of eating disorders in and of itself, tacklingthe over-investment of eating restraint constitutesan important treatment goal. Not many practitionerswould disagree. However, the ideas developedabove about the unconscious factors that may moti-vate this over-investment raise other key treatmentissues. These issues pertain to both patients andthose who endeavour to help patients in the recov-ery process. Understanding these issues maynot only be of value to practitioners of psychoanaly-tic and psychodynamic forms of treatment, butalso to clinicians working with other therapeuticapproaches.

Helping Patients

If the ideas developed in this paper about the psy-chological origins of eating restraint are correct, thenit will also be important for clinicians to focus atten-tion on questions concerning the regulation of affectin general and desire in particular. Accordingly, itmay be useful to help patients explore and expressundifferentiated affects and desires, with an aim tomaking these inner states more recognisable andcommunicable. Therapists from a wide range ofbackgrounds could integrate such work into theirown treatment approaches.

Otherwise, there are a number of treatment issuesthat do have a more direct relevance for psychoana-lytical forms of treatment, although even here a gen-eral understanding of the forces involved may helpother therapists. One such issue concerns the psy-chodynamic concept of transference. Essentially,

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transference refers to a person’s tendency to repeatpast forms of relating in the present. In psychother-apy this can be seen in forms of relating that the indi-vidual wishes to get away from, but which despitevaliant efforts are repeated time and time again. Thiscan be witnessed both outside the psychotherapeu-tic setting, but most especially within it in relation tothe therapist. In a somewhat paradoxical sensetransference can be viewed as an adaptive striving,the idea being that the individual repeats apparentlymaladaptive patterns of relating in an attempt toovercome difficulties that were faced long ago andthereby move on in life. However, since the indivi-dual lacks the tools to resolve these difficulties themaladaptive patterns repeat themselves. The psy-choanalytically trained therapist will, therefore,help the individual to become aware of these pat-terns and aid in the development of tools (such asthe development of affect regulative functions) thatwill help to resolve the difficulties, thereby render-ing further repetition unnecessary.

In eating disorders important transference issuesmay pertain to the expression of affect and how thepatient relates to the object of desire. In many wayseating disorder patients are caught in a bind. Theyneed to develop tools for integrating and expressingundifferentiated affect, but to do this they mustapproach what they are frightened of, not just beha-viourally in terms of facing a fear of eating or weightgain. They also need to approach what they arefrightened of emotionally in an intersubjectivesense. Put another way, they must approach andexperience the disorganised feeling states theywould otherwise so like to control and repress, inorder to find new ways of regulating and integratingthese feeling states. Transference comes into playwhen the therapist attempts to deal with these pro-blems. Exploration of affects and desires tends not tobe welcomed with open arms in eating disorderpatients. Since the patient will likely have interna-lised an image of a caregiver who failed to facilitatethe regulation of affects and desires, she may tend toexpect this pattern to be repeated in treatment. Inother words, the therapist will be tested, andexpected to fail. How the therapist deals with thischallenge can have a decisive bearing on his/herpossibilities to be trusted by the patient and allowedaccess to the particular areas of inner affective lifethat are so problematic and elusive.

Other transference issues that may arise pertainto specific sorts of interpersonal contingencies.Patients whose early development was charac-terised by affect regulative contingencies that lackedmarkedness may find it possible to distinguish par-

ticular affects and desires, but find it difficult tobe able to sense whether these are truly their own.In an attempt to establish some sense of boundariesthese patients may tend to focus attention on thetherapist in an attempt to ascertain what the thera-pist is feeling or desiring. What they see, however,may not reflect the therapist’s own subjective reality,and the resultant pattern of interaction may largelycome to be characterised by projective identification.That is, the patient may come to see in the therapistmany of the undifferentiated feeling-states that ori-ginate in her own inner world, but which she cannotintegrate and recognise as her own. Consequent epi-sodes of acting out may be unavoidable, and may beused by the patient to provoke the therapist into dis-closing projected feelings. Such a pattern of interac-tion, which the therapist may experience as invasiveand provocative to say the least, may also be anessential prerequisite for some patients to subse-quently initiate examination and delineation of theirown feelings and desires. How the therapist dealswith such challenges may prove to be a litmus testof the treatment. In such situations it is imperativethat the therapist understands not only what is goingon in the patient, but also what is going on in him/herself. This can limit the risk of the therapist gettingcaught up in a destructive pattern of acting out. Onthe one hand, it may be necessary for the therapist toappropriately express emotion so that the patientcan form a clearer picture of the boundaries betweenherself and the therapist. On the other hand, it willbe imperative for the therapist to shift focus backon to the patient so she can initiate exploration anddelineation of her own feelings.

Helping Those Who Help

Working with eating disorders can be extremelyrewarding. It can also be extremely demanding.In work with eating disorder patients it can be asimportant to help those who help, as it is to helppatients. One of the most important aspects of help-ing health care professionals to work with eating dis-orders is providing them with tools that can makethe patient’s behaviour and the therapist’s own reac-tions to the patient, more understandable andpredictable. Clinical supervision is, of course, animportant means to this end. Another important toolinvolves understanding the role of countertransfer-ence. Roughly speaking, countertransference is thetherapist’s counterpart to transference. It involvesthe notion that the therapist will react to the patientin ways that the therapist is not entirely consciousof. These patterns of interaction may involve the



therapist experiencing feelings and behaving in amanner in which he/she does not desire or is notaware of. Critically reflecting on how health careprofessionals interact with eating disorder patients,and endeavouring to understand the manner inwhich the patient’s difficulties may be reflected ina care worker’s own emotional reactions can bean important part of dealing with difficult treatmentissues. By understanding not only how the patient isreacting to a care worker, but also how and why acare worker (or group of care workers) is reactingin a certain way, it may be possible to limit the riskof those engaged in treatment acting out and endan-gering the goal of helping the patient take steps awayfrom established patterns of self-destructiveness.

CONCLUSIONS

Eating disorders are both clinically heterogeneousand aetiologically complex. In extending our knowl-edge of these disorders it will be important toexplore the possibilities of integrating perspectivesacross academic disciplines. The present paperbegins with the question of delineating a central coreof symptoms common to specific eating disordersyet distinct from other psychiatric disorders. Palmer(1993) has argued that the ‘over-investment of eatingrestraint’ may constitute such a defining symptom.This characteristic can be explored from a develop-mental psychological perspective. In particular,recent advances in the integration of psychoanalyti-cal theory and empirical research on infancy maybetter help us to understand the ontogenesis ofthis symptom. Building on the work of the Fonagygroup (2002) it is proposed that early developmentalanomalies may result in a need to restrict affectiveexperience in general, and the experience of desirein particular; this may later act as a predisposingfactor for the over-investment eating restraint.Clinically, these ideas suggest that the question ofhow a therapist helps the eating disordered patientto discriminate, integrate and express both affectand desire will constitute an important means ofhelping the patient to overcome her overwhelmingdesire to restrain eating. Although these ideas havetheoretical appeal, they are nonetheless speculative.It will be important to evaluate them more closely inthe clinical setting, and through systematic research.To this end continued interdisciplinary work isneeded. Relevant research could focus on delineat-ing psychopathological pathways of affect regula-tion during infancy, exploring the distinctionbetween affect and desire, and more closely study-

ing how patients with eating disorders regulateand express feeling-states.

REFERENCES

Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosaand the person within. New York: Basic Books.

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affect regulation, object relations and the central symptoms of eating disorders

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