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Art Therapies and Clients with Eating Disorders: The Fragile Board

D.Dokter (1995) Jessica Kingsley, London. 312pp. £19.95 Hardback

This substantial book makes a convincing case for the use of Arts therapies with people with eating disorders. It provides a rich source of theoretical background, case material, and descriptions of clinical method by Art Therapist, Dramatherapist, Psychodramatists, Dance Movement Therapists and Music Therapists.

The book offers insight into the issues which are commonly encountered in work with patients with anorexia and bulimia, such as a patient with anorexia's fear of loss of control, a patient with bulimia's lack of clear boundaries between self and other, the weak sense of self, fear of a persecutory object, concretisation of problems through the body, inability to symbolise and verbalise feelings.

It shows how non-verbal therapy can be less threatening and more effective than verbal therapy for this client group, for whom the therapist can represent another persecutory object. For example, Joy Schaverien States that the relationship with food is a means of mediating between interior and exterior worlds, as pictures may be. She shows how the concretisation of a patients experience in her body and acting out through food can be converted to the use of art materials, and in so doing bring about a move toward symbolisation and relating to others. Schaverien describes how the picture is used as a transactional object in place of food, facilitating the move from an unconscious fused state to separation and differentiation.

Ditty Dokter outlines the history, aetiology and treatment of eating disorders. Using the ideas of Bion, she voices doubts about whether people with eating disorders can use verbal reflection for personal change. She describes the importance of the feelings of being out of control and being controlled, and how this is acted out through the body.

Mary-Jane Rust describes her work in analytical art therapy groups at the Women's Therapy Centre, where she often encounters the client's fear of making a mess, and their difficulty with feeling separations that emerge in the ending of the group. She shows how the use of art materials allows difficult feelings such as anger to emerge in a contained way.

Paola Luzzatto notes her patients desperate unwillingness to change. She relates the recurring image of a small, vulnerable self contained in a prison. As well as a trap, the prison can serve as a protective barrier against an external persecutor. Sometimes an unreachable good object appears in the picture. Luzzatto stresses a fear of ego-weakness and shows how a relationship with a bad object can be a defence against "non-existing".

Diane Waller underlines the power of oppression of food. She relates her experiences as a female visitor in other cultures, giving some insight into the patient's fear of treatment where is an obligation to eat more food than she would wish. Waller also found her experience helpful in understanding therapists' feelings of being "devoured" in their work.

This book makes informative and persuasive reading for therapists. As the publishers suggest, it could also be valuable for any professional in this field, should they have the inclination to read about the work of other disciplines. In this respect I would have welcomed more discussion of the merits of non-verbal therapies with people with eating disorders and their place as part of a multi-disciplinary approach. More detail about working alongside other treatments would have been helpful in assessing the clients needs, making referrals, and understanding how therapy fits into the overall treatment of the patient. What problems may arise in offering therapy alongside more behavioural programmes where the emphasis may be on eating and weight gain? What experience have therapists encountered with splitting with the staff team? What kind of liaison and co-ordination took place with the other professionals?

The book shows how a body of theory and practical expertise is developing in this field, and I wonder whether there is enough to justify a separate volume for each of the therapies. Apart from the economics of publishing for a relatively small and specialised market, there are advantages and disadvantages to gathering together contributions in this way. One discipline can inform and enlighten another. As an Art therapist, for example I was interested to see how Music Therapy seems to draw on the same object-relations theory, and how it forms. I found the more directive styles descried in the dance-movement therapy and dramatherapy sections less accessible.

Some degree of compromise is inevitable in such a volume: I felt that although the theory and methods of each form of therapy were outlined for the reader, some prior knowledge was assumed. There was some overlap and repetition of theory across chapters, which may have been better presented as a whole by the Editor. This being said, the book is broadly based, including individual as well as groupwork, and in National Health Service inpatient and outpatient settings. It touches on transcultural issues, and features work with a young man, and the unusual case of a woman with Down's Syndrome.

I recommend the book as a welcome addition to the literature on therapy with people with eating disorders and to the body of literature on Art Therapies as a whole.

Mandy Keyho, Dipl. Art Psychotherapy.
Social Therapist, Henderson Hospital, Sutton, Surrey, UK.