While volumes have been written on the treatment of eating disorders, little attention has been given to the effect of the therapist's body on the course and process of that treatment. Most of the literature on the subject of the body pertains to the client, as for example, has been the case in psychoanalytic writings where the body has frequently been the focus of analytic exploration and speculation. More recently, a few groundbreaking and courageous analysts1 have shared personal descriptions of how their own bodies, whether overweight or altered by illness, have affected treatment.2,4 And within the field of eating disorders, therapists such as Rabinor and Gutwill have written about the therapist's own body image as it affects interactions with clients.3,5 But, to our knowledge, there is no published work on the impact of a therapist's body, and specifically her thin body, on her work with an eating-disordered client.

This article is the first on the subject of the thin therapist's body as both a barrier and tool to recovery. Our focus here is on issues of transference and countertransference, assumptions clients make about thin therapists, and the therapist's own body image. A second article, published in Clinical Social Work Journal, Volume 33, Number 3, examines in more detail, the expression and enactment of these transference-countertransference dynamics in treatment.

People with disturbed body image frequently want to disown or compartmentalize parts of their bodies. At the same time, they are overly preoccupied with certain body parts, such as thighs and stomach, endlessly obsessing about them and wishing desperately that they were different. Women with disturbed body image almost always compare their bodies, and body parts, to those of other women. When the other woman is their therapist - the therapist, the client and the treatment are affected. As thin therapists, we are confronted with a variety of beliefs about our thin bodies - beliefs that our clients hold as truths about our lives, and about us. These ideas include beliefs about us as people and as therapists, and involve assumptions about our attitudes, morality, competence, and mental and physical health. Following are a few of the most common assumptions about thin therapists and their bodies.

1. The therapist has or has had an eating disorder.
2. The therapist likes her body and feels comfortable in it.
3. The therapist is thin, therefore, she is: happy, successful, married, young, desirable - all of the traits clients believe they would attain if only they could lose or keep off weight.
4. The therapist disapproves of, and therefore cannot help large/fat clients because her own experience is so far from theirs.
5. The therapist is physically weak, but morally strong.

These assumptions are particularly powerful, in that they can have a pronounced effect on the therapeutic relationship and the course of the treatment. The first one tends to emerge early in treatment. After all, our clients wonder, what is a skinny therapist doing working in the field of eating disorders? It is common for people whose histories include substance abuse to work to help others recover. Indeed, many of our colleagues identify themselves as people who have recovered from an eating disorder. There is a tendency to assume, or at least question, the presence or history of an eating disorder in a thin therapist. This is often veiled in the question, "How do you stay so thin?" implying the therapist takes some action toward this end. Like some of the other assumptions, this one is held not only by clients, but also, at times, by the colleagues of thin therapists.

For example, one prominent group therapist, assuming a thin supervisee had had an eating disorder, suggested she disclose it to the group as a way of facilitating trust. In this case, the therapist had no such history to disclose. This created an angry reaction in the therapist. She thought, "How dare you assume I've had an eating disorder because I have a thin body." What would the supervisee's reaction have been had she had an eating disorder? Would the supervisor have made this assumption if the therapist were of average or above average size? Just as beliefs about thin therapists vary, thin therapists, depending on their personal experience, respond differently when this assumption arises, whether in supervision or in treatment with eating-disordered clients. What is predictable is that the assumption will come up, either in thought, in fantasy or in words and it will have an appreciable impact on the course of the therapeutic interaction.

The issue of whether the therapist has had an eating disorder can operate powerfully in a day treatment setting where staff members eat meals with clients. One client, for example, fantasized openly about the thin therapist eating pancakes and eggs next to her. "I can't believe you can eat that much. This must be the only meal you eat all week!" The therapist immediately felt insensitive for eating what she really liked, without considering that the client felt unable to indulge herself. When observing her countertransference, the therapist noticed paradoxical feelings. She felt the client's feelings of superiority regarding eating in a more restrained and controlled manner, and this triggered messy, chaotic, gluttonous feelings in her. Yet she also acknowledged the client's feelings of jealousy, which seemingly idealized the therapist and her ability to eat freely. Invited to share her thoughts about the therapist and her body, the client elaborated that she did not believe it possible to eat and remain thin. If she allowed herself to imagine the thin therapist eating regularly, she also imagined that the therapist would have to exercise vigorously every day. These reactions served as vital information for the treatment, to underscore the extreme measures the client was willing to take to preserve her anorexia and to deepen/complicate/enrich the nature of the client/therapist relationship.

Many clients share the secret or expressed fantasy that the thin therapist is healthy now, but at one time had suffered from an eating disorder. For most, the "fact" that the therapist has recovered enhances or, sometimes, revitalizes the hope for personal recovery. Some clients, on the other hand, deny the thought that their therapist has an eating disorder history. They prefer to think that therapists are always in good mental and physical health; else they may be subject to relapse and be unable to offer any real help. In the former instance, the client is usually eager to hear the "truth" about the struggle and the recovery, whereas in the latter case, a client may be unusually "bored" or uninterested to learn anything about the therapist's life.

When clients are asked directly about their feelings toward the therapist's body, they frequently deny noticing or feeling anything at all. However, if the therapist pursues the issue and encourages exploration, a myriad of feelings often emerge. Therapists who describe themselves as overweight have said that their thinner, eating-disordered clients are frightened while with them because the clients are reminded that they could end up looking like them if they are not careful. On the other hand, once clients are open to the possibility that they do have feelings about thin bodies" therapists hear comments such as, "When I look at your thin arms, it makes me want to run out of the room. I'm filled with self-hate because my arms are so fat and grotesque."

When a remark like this is made by a large woman, thin therapists can find themselves feeling inadequate, wishing for bigger, rounder "earth mother" bodies, to convey a sense of safety and security. Yet, later on that same day, when an anorexic client is dissecting her body and sharing her repulsion about her "disgustingly fat" arms - arms, she declares, that are so much larger than those of the therapist - a thin therapist can forget all about her wish for a bigger body. Instead, she may fall into distortions of her own, and begin to wonder, "Am I really as thin as I think I am?" In other words, a therapist's body image can fluctuate given the body size of the client, and the effect the client has on the therapist. Important information can be gleaned from these countertransferential reactions, leading to useful exploration and a deepening of the therapeutic connection.

Once acknowledged, other responses to the therapist's thin body can be very surprising. A bulimic client (who is of average weight and curvaceous shape) feels intense body hatred and states she will never be happy with her body and her weight. She has tried every weight loss gimmick on the market, and feels the constant disappointment of yo-yo dieting. She believes her size will keep her alone forever. In session, she frequently shifts around in her chair, rearranges her clothing, attempts to hide certain body parts, and appears tortured in her body. Conflicted, she describes her discomfort with both skinny and fat people. "Fat people gross me out and make me angry. Skinny people make me jealous." When the thin therapist brought attention to her own body and wondered about any discomfort toward her and her thin body, the client denied such feelings. Instead, she stated that she is relieved the therapist is thin because she respects how "together" she believes her to be.

In contrast to Burka's hypothesis that her "earth mother" body fosters a positive maternal transference, for this client, a rounder, softer body evoked strong negative feelings. What emerged in the treatment was the fact that the client was raised by an extremely obese, neglectful mother. As a result, she held a lifetime of rage toward her mother and, at the beginning of therapy, experienced the thin therapist as a safe and compassionate figure in comparison. As the treatment progressed, this client realized she turned her rage on herself. Then, as she became somewhat more comfortable with her own body, she was able to acknowledge and explore additional feelings about the therapist's body. To be thin was a safe, enviable haven that she would never have access to, and so she not only respected her therapist, but also felt inadequate, depressed and intimidated in her presence. Now, near the end of therapy, the client and therapist have shared a great deal about the "presence" they have for each other. The client feels more and more at home in her own body. She is enjoying her curves, does not fear becoming like her mother and is less prone to idealize her therapist and the therapist's thinness.

A therapist's thin body is certain to create strong, complex feelings in eating disordered clients, just as it will undoubtedly affect the therapist herself, as she brings her own body image into the office and attempts to form a therapeutic alliance. Consequently, it is important for the therapist to be self-aware both externally and internally. When clients who suffer from self-loathing in relation to their body enter treatment, it is common for them to disavow any feelings about the therapist and/or her thin body for a considerable time. Just as much, the thin therapist can struggle with an unspoken, unacknowledged desire to be larger, rounder, or softer, unconsciously or consciously wishing this will somehow ward off a potential negative transference. But, just as it is the therapist's responsibility to work toward knowing how she sees, feels in, and feels about her own body, it is up to her, over time, to invite the client's feelings and thoughts about her own body and the therapist's body as well. Only then will the therapist and client begin to have the freedom necessary to fully explore the themes that emerge between them.

*This article has been edited and reprinted with permission of the Renfrew Center Perspective.

Mary Anne Lowell, LCSW, is a psychoanalyst in private practice. She is supervisor at CSAB and faculty advisor in the Fordham University Graduate School of Social Service. Formerly, director of admissions and outpatient therapist at The Renfrew Center of New York, she has appeared on national TV talk shows as an eating disorders expert and provides educational training to professionals and the public.

Lori Lynn Meader, LCSW, is in private practice in New York City, specializing in the treatment of eating disorders, body image, creative blocks and performance anxiety. She utilizes the Focusing technique and other body-centered work in her practice. The former director of administrative and outpatient services at The Renfrew Center of New York, she conducts interactive workshops in the public, private and academic sectors.