BOOK REVIEWS: Integrated Treatment of Eating Disorders

Reprinted from Eating Disorders Review
May/June 2008 Volume 19, Number 3
©2008 Gürze Books

Integrated Treatment of Eating Disorders

Beyond the Body Betrayed
Author: Kathryn J. Zerbe, MD
280 pages, $35.00
©2008 W W Norton & Co.
Order online at

Reading Integrated Treatment of Eating Disorders, by Kathryn Zerbe, is like listening to a symphony written by a master composer at the height of her or his powers. Actually, the book takes the form of a concerto with a strong first movement, lyrical second movement, and a lively finale.

The first section of the book provides a road map to the opening, middle, and termination phases of treatment. It suggests ways of conceptualizing interventions and how to put them into words. The hallmark of the opening phase is to help the patient tell her or his own story. The approach is based on psychodynamic theory but adds educational, cognitive-behavioral, motivational, and pharmacological advances. In fact, there is a willingness to “borrow and blend” from all modalities and therapeutic traditions.

Subsections of the opening phase include “the patient’s theory of the illness,” “engaging the patient by recognizing strengths,” and “cultivating the true self.” The goal of “finding a sense of one’s true self,” as developed by child development expert D.W. Winnicott, is one of the recurring themes of the book. This goal is important, not just for symptomatic relief, but also for better interpersonal relationships and “more effective engagement in the life cycle.”

There are numerous practical sections on initial assessment, patient education, and working with a multidisciplinary team. Throughout the book, there are many concise and illuminating clinical examples and many helpful tables in each chapter, ranging from “Beginning a Dialogue with the Patient” to “Medical Complications of Anorexia and Bulimia Nervosa.” There is also an extensive reference section and helpful index.

The middle phase of the treatment is the longest. Unfortunately, the vast majority of patients never reach this phase, due to patient reluctance, third-party limitations, and lack of family support. The “hallmark” of this phase is the establishment of a durable therapeutic alliance from which a consolidated sense of the patient’s “true self” can emerge as well as better symptomatic control. Some of the therapeutic issues include working with the patient’s overly harsh self-criticism, containment of the patient’s “emotional wave,” and limiting self-destructiveness. Other goals include encouraging competency, promoting intimacy, and helping the patient grieve over the symptoms, which have been an important part of her or his identity. Deconstructing the meaning of food and addressing body image are other important aspects of this phase of treatment.

In the third chapter, which addresses the termination phase, both the therapist’s tasks and the patient’s reactions are extensively discussed. The chapter begins with a terrific quote from psychotherapist Dr. Elvin Semrad, “The only part of the world that is wise about the proper time to push the young out of the nest are the birds, and even they take a calculated risk. But they’re willing to do it.”

The next section looks at eating disorders treatment through the “lens of the developmental life cycle.” Phase-specific issues are examined for adolescents, adults, middle-aged, and older patients. In the chapter on adolescence, the protective function of the eating disorders is examined, as are the roles of culture, genetics, the brain, and temperament. Both family involvement and the adolescent’s “developmental challenge of establishing an identity” are discussed with suggested “high-yield” interventions.

In the chapter on adulthood, both cognitive-behavioral and interpersonal strategies are outlined. Adult developmental tasks are discussed, including the need for acceptance of the lack of perfection in oneself and others. Parenthood, pregnancy, and infertility are also discussed.

For the older patient, the midlife transition involves “mourning actual losses, recognizing the meaning of these losses to the self, and gaining a sense of equanimity.” Biology and culture are discussed, as are specific symptoms of eating disorders in middle and late life.

The final section looks at special issues such as the assessment of outcome and the management of transference and countertransference. Dr. Zerbe, who spent more than 20 years on the staff at the Menninger Clinic, meets the “extraordinary challenges” that the transference and countertransference reactions present with the highest level of clinical acumen, psychoanalytic wisdom, and scholarship.

There is also a chapter on the patient’s sexuality, which so often goes unaddressed in our field. This includes exploration of common sexual problems in eating disorder patients, with discussion of biological factors, medication, and psychological issues.

There is also a much-needed discussion of sexual minorities. It is worth remembering that our society’s current desire for “hard bodies” began in classical Greece, where there was great focus on daily exercise at the gym, diet and exercise manuals, personal trainers, and “six-pack abs.” However, as Simon Goldhill, a professor of Greek literature at King’s College, Cambridge, discusses in his recent book, Love, Sex, and Tragedy, “the dominant model of erotic liaison” was the desire of a free male adult citizen for a free boy between the ages of puberty and the arrival of a beard.” Because of the “fierce patriarchy” of Greek society, female desire remained hidden we have no examples of any real women who loved women. Even for Sappho we know almost nothing. “Everything else that passes for a biography is made up by ancient or modern scholars on the basis of her poetry, or, since there are only a handful of fragments and a couple of poems that can still be read, on the basis of imaginative projection.”

Kathryn Zerbe’s book ends with a wonderful epilogue that has the tone of elegiac poetry. The noted Hasidic master, Baal Shem Tov, is quoted on the need to “listen intently and respectfully.” Dr. Zerbe’s effort to carry forward the great psychoanalytic tradition of “cultivating the listening ear” is inspiring and brings to mind another of the Baal Shem Tov’s well-known sayings: “The sounds of silence are more elevated than the sounds of speech.”

Bravo, Dr. Zerbe, Bravo!

— Russell Marx, MD

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