Eating disorders: A contemporary introduction. By Tom Wooldridge. Published by Routledge: London, 2023. pp. 136. £28.99 (paperback). Part of the Routledge introductions to contemporary psychoanalysis series

Tom Wooldridge sets himself an ambitious task for this slim volume, part of Routeldge's series of Contemporary Introductions. He hopes it will serve as an introduction to psychoanalytic thinking for clinicians already working in the field of Eating Disorders, as well as providing an overview of the contemporary understanding of this patient group for those familiar with psychoanalytic ideas, students and more general readers. It is a sign of his considerable skill as a writer but foremost as a conceptualiser of the inner world of patients suffering from eating disorders that he achieves all of this and more. The book aims to consolidate the important accumulation of thinking about eating disorders that the psychoanalytic community has contributed over many decades. Treatment of mental health conditions with such high mortality rates as eating disorders have (understandably) emphasised interventions focused on symptom reduction and management. Wooldridge hopes in this book to draw our attention to the underlying psychological difficulties which may remain, even if the patient experiences a full recovery from the eating-related symptoms following treatment. I was asked to review this book in my capacity as a trainee psychodynamic psychotherapist whose MA dissertation was in the area of eating disorders. This involved conducting a literature review of psychodynamic writing on the subject of anorexia, where I came across Wooldridge's previous overview of this area: ‘Psychoanalytic Treatment of Eating Disorders: When Words Fail and Bodies Speak’ (Routledge, 2018). That volume provided a much-needed bringing together of contemporary psychoanalytic thinking on disordered eating, including contributions from Kathryn J. Zerbe, Danielle Novack and others. It also contains a chapter by Wooldridge himself on pro-anorexia Internet forums, some of which is repurposed in the excellent final chapter of this volume. Whilst that collection gained breadth from its array of contributors, Wooldridge's new volume gains focus and coherence from having Wooldridge as the sole author. He decides to structure the book using nine chapters, each exploring one way of thinking about the psychic structure of patients with eating disorders. Or rather, some patients with eating disorders. Wooldridge is at pains to draw our attention to the significant variation in psychic functioning among patients even if their overt symptomatology may be the same. This is one of many ways he draws us back again and again to imagining the individual behind the anorexia, bulimia or muscle dysmorphia. These patients can often report feeling that their individuality is obscured behind their diagnosis, that clinicians struggle to see things from their perspective. This perhaps emphasises the difficulties with individuation and separation which are often a significant factor in this patient group. This important point emerges again and again throughout the volume in different ways. In the first three chapters, which focus on alexithimia, early relationships and mourning, Wooldridge manages to give something of a crash course in object relations whilst also providing the scaffolding which underpins his thinking about the eating disorder patients he works with. He gives a precis of Bion's theory of containment, Klein's ideas on object relations and Freud's understanding of the centrality of mourning with admirable clarity and succinctness. Some of these explanations are returned to, and somewhat repeated later, in the book, which is perhaps necessary when trying to introduce general readers to this field. Even for those more familiar with these core concepts, Wooldridge's treatment is fresh and links them to lesser known (to me, at least) contemporary thinking. Particularly prominent is his foregrounding of Shabad's notion of the ‘traumatic theme’—a useful, simple term for describing early relational trauma and the object relations difficulties which arise from it. Having established these core concepts, Wooldridge sketches out some of the various impairments in the relationship with the primary caregiver which may contribute to eating disorders in later life, many of them involving an emotionally unavailable or unresponsive mother. He shows how something particular happens in the development of eating disorders which involves the internalisation of something abject, rotten or foreign into the core of the object world. He describes the strong countertransference experience of being projected into or intruded upon that clinicians often remark upon. In doing this much, Wooldridge already provides a clear and cogent overview of the main features of psychoanalytic work with these patients. In addition, Wooldridge deftly weaves in an impressive amount of theoretical contributions without it ever feeling overwhelming or muddled. It is impossible to mention even a significant minority of them here, but it may be beneficial to mention a few to give a flavour of the richness of the text. In the first chapter he lays out Lecours and Bouchard's idea of mentalisation, sketching out the four vertical and five horizontal dimensions involved. Wooldridge uses this to illustrate how eating disorders can be viewed as a failure of mentalising or containing affect resulting in their expression being stuck in the body. Later, he introduces Caston's thinking around agency as a psychoanalytic idea with the three markers of agency—reversibility, self-observation and appropriateness. Wooldridge conceptualises eating disorders as a crisis of agency. This central idea picks up a thread first identified by Hilde Bruch in her seminal work on anorexia as a struggle for mastery and autonomy. Wooldridge takes these concepts, and many more, and synthesises them to provide a holistic framework which is applied in subsequent chapters to understand the variety of experiences encapsulated under the umbrella of eating disorders. Wooldridge's choice of themes will be familiar to clinicians who have worked with this patient group—disgust at bodily functions, intolerance of desire, body-mind dissociation, emerging gender identity in adolescence. He usefully gives overviews of psychoanalytic thinking in these areas, but also uses them to develop his underlying framework. Of particular interest to me was his thinking around how agency may be experienced differently in males or females depending on the nature of their gender identifications. He highlights how in some cultures female identity may be associated with passivity rather than agency, foreclosing avenues for feminine outlets for a desire to be active. Self-starvation or binge eating may become ‘acceptable’ fora for these healthy impulses. Wooldridge here helpfully holds in mind how the impulse behind disordered eating can be a healthy drive for individuation. This facet is often harder to hold in mind alongside the more immediate destructiveness and aggression. The theme of aggression is picked up and expanded in his chapter on the role of fathers and the paternal function. Since Bruch documented the pattern of domineering and intrusive mothers in the patients she worked with, there has been a preponderance of writing on the role of the mother–daughter relationship in anorexia and bulimia. Wooldridge draws together some of the growing thinking of the last 20 years (perhaps most significantly the concept of ‘father hunger’) which has grown up around the difficulties in father–child relationships which may contribute to eating disorders of all kinds. This broadens the focus to see how a father who is absent or has difficulty with his own aggression may not be able to be used by the child to model and assist their own task of separation and individuation from the mother. This chapter also provides some vivid clinical examples of muscle dysmorphia, perhaps the least familiar and understood of the eating disorders. This book is an excellent psychoanalytic introduction to the area of eating disorders, providing an impressive balance of depth and breadth. It provokes the feeling of wanting to read more in the various different directions it touches on—alexithimia, relational thinking, the healthy uses of pro-ana forums—whilst still feeling substantive in its own right. It manages to serve not only as a consolidation and testament to the decades of psychoanalytic thinking on eating disorders, but importantly also offers Wooldridge's own sensitive and creative understanding as a framework for work in this area. Indeed, it provided such compelling tools of analysis that I found myself coming back in my mind to non-eating disorder patients who benefited from the thinking in this book. Wooldridge manages to provide a way (or ways) of thinking about this patient group which feels specific to them, but also richly applicable to the inner world of many patients who struggle with separation, denial of need or somatic complaints. Most crucially, Wooldridge shows how psychoanalytic thinking helps relentlessly focus on the individual behind the eating disorder, by returning to their particular early object relations and their struggle for agency. In a field where clinicians and patients may both feel dispirited by the prognosis for recovery, Wooldridge's book offers firm footing to work with patients towards ‘the growth and development of the personality’ which, as he powerfully suggests, is ultimately the psychoanalytic understanding of recovery from an eating disorder.