This paper is one of a collection of archived papers written for students on the Eigenwelt psychotherapy training programme, now the Tariki Training Programme in Other-Centred Approach.
INTRODUCTION EATING, NOT EATING: WHEN IT BECOMES A PROBLEM Many women have some problem with food. Some eat compulsively, some starve themselves. Others get into wild patterns of eating, starving, and laxative abuse. There are many theories which seem to help us to gain some understanding of the behaviour, but in the end, for each woman a whole collection of powerful emotions may be involved, which are individual to the woman herself. Food has particular qualities which give it deep symbolic meaning for all of us. It is essential to life. It is the source of one of the strongest bonds created between mother and child. It is given as reward for preferred behaviour. It is forced on the reluctant child by anxious parents. It is at the centre of many social gatherings. The language of food pervades our language, and its substance our culture. At the same time, our bodies themselves are also subjected to scrutiny by the culture. We are surrounded by images of women, and men to a lesser extent, who are thin and young. Shops stock clothes in smaller sizes. By the time they reach adulthood most women and many men have developed some degree of discomfort with the shape or size of their bodies. When women talk about their feelings about their eating and behaviour around food and their bodies, different threads seem to emerge. Biting down anger. Filling the emptiness. Building a wall between oneself and the outside world. Longing and forbidding. Originally eating disorders were divided into two categories, compulsive eaters and anorexics. In the late 1970s a third category of women were identified: the bulimic women. Since this time more complex categorisations have developed. The importance of defining a particular woman's problem can be both useful and misleading. Many women move from one category to another several times during the period of the problem. Some particular patterns are being recognised, and the history of a woman's behaviour as well as her present behaviour may be used in determining treatment. On the other hand, each woman will have her own unique relationship with the problem and with food. The element of personal meaning needs to be addressed alongside any programme of help. Often women will not fit exclusively into any one category. Anorexic women often binge from time to time, and may well use laxatives. Compulsive eaters may starve themselves at times. On the other hand the broad categories are generally identifiable both in the behaviour and in the body size of the women. They may be linked to particular thought patterns. DEFINITIONS The three main categories of eating disorder are: ANOREXIA NERVOSA: In which the woman starves herself, losing weight, often to a point where her health is affected, periods stop, and eventually the woman's life may be threatened. This condition affects mainly girls and women, the ration of women to men being between 20:1 and 10:1. It is generally seen as a young woman's problem, mostly occurring between the ages of 15 and 25, although it does affect a lot of women outside these age parameters. There is evidence that the ages at which it is recorded are getting lower. There is evidence that suggests that whilst there may be a genetic factor for men in this condition, for women this is not the case. It is concluded that the social pressures to be slim are a big factor in the rising incidence of anorexia. BULIMIA NERVOSA: In which the woman alternates between binges and self-induced vomiting. Bulimic women keep their weight within a "normal" range. (Those women who reach very low weights are defined as bulimic-anorexics) Some women vomit only occasionally, others get into extreme patterns, with huge binges in which normally unappetising food is crammed into the mouth, followed by violent attempts to get rid of it. Laxatives are also abused, often in huge quantities. This disorder affects women of all ages, but the predominant age of onset is between 20 and 35. It is often found useful to distinguish between women who have previously been anorexic (a common sequence) and those who have not. COMPULSIVE EATING: Most of us will from time to time eat when we are not hungry, either to comfort or distract ourselves. For some women this can reach problematic proportions when food becomes a focus for life, and weight reaches disabling levels. Evidence varies about the correlation between diet and weight. Some women feel themselves to be compulsive eaters, whilst staying within "normal" weight ranges. Other women may over eat without eating compulsively. This pack refers predominantly to women because women are the main sufferers from eating disorders. This does not, however mean that men are immune. For them there may also be pressures around food. Whilst issues may be different in specifics, many of the approaches suggested are equally applicable to men and women MODELS AND THEORIES There are many theories about the causes, and consequently the treatment of eating disorders. One thing is clear, no-body has the conclusive answer. At the same time, anyone working with women who have problems around food will recognize some of the patterns described, and may find certain ideas provide useful metaphors with which to clarify the problem. The danger is, perhaps, that a particular model is taken too rigidly, and the helper's ability to hear the individual woman's story becomes limited to those facts that fit the model. There is also a danger that behaviour is seen as pathological, which will set the client apart in the role of "sick person", and may deny the inherent sanity and strength in her position. PSYCHOANALYTIC 1. The Freudian model: The theory of infantile sexuality suggests that each child between the ages of roughly two and seven becomes engaged in a phantasy of seduction of the opposite sex parent. This is called the Oedipus complex for a boy and the Electra complex for a girl. The phantasy romance inevitably ends in frustration and the manner in which this trauma is handled has long term consequences for the personality development of the child. Ways in which this developmental stage can go badly wrong include both those situations in which the parent is unnerved by the child's advances and responds with harsh rejection and those situations where the parent exploits the child's affection and sexual abuse takes place. Either of these scenarios can leave the child with intense feelings of guilt and anxiety. In this model, therefore, vomiting may be seen as a way of trying to expel shame, starvation as a means of restoring purity, and excessive eating as a means of comforting anxiety. 2. Object Relations Theory: Post-Freudian theorists have given most attention to the period before the Oedipal/Electra complex develops and place great importance upon the nature of the bond between the new-born child and the mother who is the first "object" of the child's attention. The mother becomes both a "good object" and a "bad object" as she inevitably both satisfies and frustrates the baby's needs. The theory suggests that the person affected by an eating disorder may be unconsciously attempting to keep alive a memory of the nurturing figure (or "good object"). The problem would be seen as resulting from failure in early nurturing, and difficulties over separation. FEMINIST PSYCHODYNAMIC The Women's Therapy Centre in London have produced an impressive number of books on women and eating. Most of these take a broadly psychodynamic model, but incorporate sociological ideas about women's roles. Eating or not eating is seen as a way of coping with a difficult world, a way of keeping unacceptable feelings at bay, and saying the unsayable. The ideas expressed are complex, but certain themes emerge. One theme revolves around the issue of "needs". The feminist model defines in some detail the way that women grow up with a sense that they cannot expect their needs to be met (Understanding Women, Eichenbaum & Orbach). This expectation is transmitted through the mother daughter relationship from generation to generation. The same authors in their book What Do Women Want talk about how women are the emotional care-takers in relationships, meeting the needs of their partners whilst "starving" themselves. Different disorders are seen as different solutions to the problem of unmet needs: The anorectic's refusal to eat being a refusal to acknowledge needs, the compulsive eater's desperate insatiability, a struggle to fill an emotional gulf. Three important themes are Boundaries, Power and Sexuality. The theme of boundaries is seen both in issues of control and lack of it, and in the desire to alter bodily boundaries. The fat woman may be using her fat to say "keep off", particularly to men (Fat is a Feminist Issue by S. Orbach). There may also be "boundary issues" in the sense of not yet being willing to separate from the mother who has provided insufficient nurture. Power is a theme which pervades writing in this field. A woman's feelings of powerlessness and low self worth are bound up with her relationship with food. Eating can be a statement of anger. It can also be a matter of "carrying some weight" or "having some weight to throw about". Eating behaviour is also strongly related to the person's feelings about sexual availability. Anorexia physically returns the woman to a pre-pubescent condition. Excessive eating may also be seen as a rejection of sexuality or as a substitute for it. SOCIOLOGICAL Images of women: how to be size 10. Women are surrounded by injunctions to lose weight, to develop a better shape, to look young, sexy, sun-tanned, thin. Both direct advertising and more indirect images surround us as we grow up. Few women are happy with their appearance. Many go to extreme lengths to change it. Many people do not find it surprising that some women's dissatisfaction with themselves finds expression in extremes of eating. (Woman Size, by Kim Chernin) Women's role as providers: Food is for other people. In most families women are the providers of food. Activities connected with food, such as shopping, cooking, and clearing away may take a considerable part of their day. At the same time magazines dictate ever more exotic and nutritious menus. It is not just good enough to provide a meal. It has to be the right meal. Much of this caring is not appreciated. The woman may be left feeling a failure. If the children want junk food, she must either give in and fail to feed them properly, or face a pile of uneaten food. Small wonder so many women end up finishing the scraps in the kitchen, rather than throwing their day's work into the bin. THE ADDICTIVE MODEL The view eating or dieting as an addiction can be helpful. This addiction may be seen as an emotional dependency on food and the feelings of comfort which it produces. It may also be a physiologically based addiction on the "high" produced by endorphin released in the brain of someone suffering starvation, or to the new body chemistry produced by self-induced vomiting. It has also been suggested that certain foods may be addictive to sensitized people. There is often a link between food problems and other addictions, such as alcohol, drug and nicotine dependencies. PHYSIOLOGICAL FACTORS Physical factors clearly play a part in this difficulty, bridging as it does the mind-body divide. Starvation produces its own states of mind. The starving woman will find her capacity to think and reason reduced. The world will be seen in a polarised way. Everything will be either good or bad, friend or foe. reactions will be "of the moment". Bulimia too disrupts the body chemistry, producing mood changes. There is also suggestion in some sources that particular foods can act as triggers to a binge. For some women a strict, but not necessarily slimming, diet may be an answer. This type of approach may also work because it offers an alternative way of restricting the diet and gaining the feeling of control, without actually starving. The compulsiveness is channelled. On the other hand some foods certainly do seem to start binges. Chocolate is often cited. Whether the cause is physical or psychological is unclear. Levels of blood sugar can also be a triggering factor. Sugary foods can produce a rush of insulin followed by a dip in blood sugar levels and a craving for more sweet things. FAMILY FACTORS A number of features seem to emerge in the relationship between the woman with an eating disorder and her family. Sexual abuse is very commonly linked to subsequent eating problems, the behaviour seeming either to block out memories, eradicate sexuality, or to attempt to evacuate shame through vomiting or laxative abuse. The dynamics of the family may be quite disturbed. The woman herself may be seen as the "sick member of the family", with all the others then able to deny their part in any problems that exist. The woman who is anorexic may be very clingy towards her mother, and distant to her father. PHENOMENOLOGICAL APPROACHES A phenomenological approach will not involve the use of a "model" in the sense of those listed above, Rather the therapist will be concerned to experience the client's world with an attitude uncontaminated by preconceptions. The concern would be with perceptions of the client. The subjective view of self and of the world and the meanings attached to life experiences. A phenomenological explanation of these conditions would focus upon the question of self-image and body-image. Distortion of body image is common. Exploration of that distortion can uncover layers of personal meaning. Phenomenology is also concerned with the psychology of figure and ground ie how much does one want to stand out and how much does one want to hide. Eating behaviour can produced a body that says "I am here" when the person inside it is not in a position to speak out. Or it may say "I do not want to be here", a visible sign of inner sadness. Whatever the personal message, giving space to voice it in words may free the body to find its own size. BEHAVIOURAL APPROACHES One of the most widely used models in the treatment of eating disorders in medical establishments is the behavioural one. This rests on theory which asserts that all behaviour is learned and ultimately controlled by the environment, and that anything that has been learned can be unlearned. Behavioural approaches work on the principle of reinforcement (ie reward) of desired behaviour. In anorexia this may involve hospitalisation, withdrawal of privileges (including visitors, books, or even the chance to have a bath of go to the toilet unaccompanied.) These "privileges" are then gradually returned as the patient complies with the programme of refeeding. In itself this treatment pays little attention to the woman's feelings, or underlying issues. It treats the behaviour around food at face value. Behavioural methods may be combined with cognitive approaches. COGNITIVE APPROACHES Cognitive approaches are based on looking at thinking and lines of reasoning. They will often include an educatory element.The cognitive therapist may be working with associations, helping the client to identify triggers which start binges, or false assumptions behind eating behaviour. Cognitive approaches are often combined with behavioural and psycho-educational approaches. A combined approach may involve identifying possible pitfalls and taking avoiding action before, for example, a binge. This may be done by pre-planning meals to avoid impulse eating, paying attention to the manner of eating, or scheduling meals for earlier in the day. Education may include nutritional information, information on eating disorders, and discussion of pressures to be slim. A client embarking on this type of programme is likely to be asked to keep records of her own eating patterns, so that she and her therapist can identify her particular problem areas. THERAPEUTIC ACTIVITIES FOR USE WITH GROUPS AND INDIVIDUALS HUMANISTIC APPROACHES The most important part of any therapeutic encounter is that the client feels deeply heard, respected and valued by the therapist. Beyond this, the client may find particular activities helpful. It is important when introducing activities to have a sense of what they might offer, but it is also important to be open to any learning or change that arises spontaneously, whether or not it is linked to the original thinking behind the task. This section of the pack lists a number of areas of attention. most of these include specific activities. Some activities may offer a number of functions, and are listed in more than one section. Tasks may be offered with a narrow intention, or in a more open ended way. AWARENESS RAISING One of the most basic tasks in therapy is the raising of self awareness. For the woman who suffers from difficulties around food, a focus on food has been a way of avoiding awareness of self. Therapy may help the woman to focus on her relationship with food, the meaning of the food itself, the way she feels about her body, and the way these behaviours fit into the wider picture of her life. It will often be a time for looking at the things that she has been able to push to the back of her mind through her involvement with food. CONTAINMENT / CLOSENESS AND DISTANCE The feelings expressed by women who are discovering the world behind their abuse of food are often primitive and terrifying. Monsters glimpsed sideways. Images often reminiscent in their ferocity of Melanie Klein's concept of infantile rage. Providing conditions which make it safe enough to confront these feelings can help the woman to release herself from the power of their grip. In working with different media, it is possible to vary the closeness of what is being described/felt. A woman may talk about feelings in terms of "you" or "one" instead of "I". Encouraging her to use "I" may bring her more in touch with the personal feeling in what is being said. Similarly bringing attention to body feelings either by explicit invitation, or by reflection of observed body language may also help to "take her into her feelings". At other times however, it is some distancing which is needed. A chance to see things as more manageable, or to take a step back and see the wood from the trees. Here some sort of projective technique is helpful, such as art, sculpting, or writing. In either case it is important that a sense of containment is offered in the form of boundaries either in the group or individual therapy. Activities: REFLECTIONS OF USE OF LANGUAGE BODY AWARENESS ART & WRITING SCULPTING & OTHER SPATIAL WORK BOUNDARY MAINTENANCE EXPRESSION AND CATHARSIS A central part of much therapy is the expression of that which has previously been kept inside. This may be material of which the client is all too aware, but which brings up feelings of shame, self-hate, fear, anger, or other emotions unacceptable to the client. It may be feelings or experiences which have been deeply buried, but which drive current preoccupations like that with food or with self hate. As eating or starving is often a way of keeping unbearable feelings at a distance, finding ways to express them can be the start of change. However, given the terror of these feelings, that expression is often a long, painful process. It is important to provide a safe space for this to happen, and accept the client may need to distance feelings. Activities: SHARING IN A GROUP WITH OTHERS INDIVIDUAL "TALKING" THERAPY PAINTING & ART BASED WORK DRAMA & PSYCHODRAMATIC TECHNIQUES CONSCIOUSNESS RAISING Given the social dimension involved in issues around food, it can be useful to challenge the assumption, implicit in a lot of therapy, that it is all the individual's pathology that is causing the problem. Society can be sick too. On the other hand too political a message denies the individual element, and often leaves the woman stuck in feelings of anger and oppression. There are things which are wrong in the way we are brought up to think about food and our bodies, but we also have the possibility for personal change and personal responsibility. As therapists, we need also to be clear about our own motivation. Wider social issues are important, but can be a minefield for the unsuspecting therapist. It is all too easy to be working through ones own issues through the client. Activities: DISCUSSION GROUPS LOOKING AT IMAGES IN ADVERTISING AND THE MEDIA USE OF RESOURCE PACKS etc (There are a lot of good materials produced. Using someone else's material can preserve a more neutral role for the groupworker.) HIGHLIGHTING & CHALLENGING ASSUMPTIONS IN COUNSELLING GAINING INSIGHT When a woman feels able to explore feelings which have previously been lost in the turmoil of eating behaviour which has got out of control, the insights which result may help her recognise and leave the past, and make choices about her future. Clarifying the new thoughts, feelings and memories can help. Techniques listed in other parts of this section will help serve this purpose. Some form of ongoing journal may also be helpful. CHOICE, CHANGE, AND PERSONAL POWER Power is a central issue for most women caught up in the struggle with food. Whether the woman talks of feelings of worthlessness, a need to gain control, or a statement of defiance, an underlying feeling is often that of powerlessness. Thus most of this behaviour is, in some sense, a struggle for power. The feeling of powerlessness can be disabling, giving little sense of choice, and a negative sense of self. In understanding this struggle for power, it can be useful to recognise the connections between power and love. Power can be a substitute for love. Clients who says they feel powerless may be saying that they are not loved. Power seeking may be seeking for love. The feeling of powerlessness is often displayed in a fatalism and in a feeling that what is now always will be. Often change seems impossible. Women will ask "Have you known anyone as bad as me who has recovered?" In counselling it is important to highlight any changes or choices made by the woman: "Last week you felt depressed, today you are angry" "You chose to paint that blue." "Right now you don't want to eat" This can happen in the group too, and differences between women, which are likely to be the source of a lot of discomfort, can be highlighted. Options and choices for the future may also be explored. Activities: REFLECTION OF CHOICES, DIFFERENCES, CHANGE JOURNAL KEEPING ART, WRITING etc TO EXPLORE FUTURE OPTIONS EXPLORATIVE EXERCISES, eg johari's window PSYCHODRAMA AND SCULPTING GESTALT TECHNIQUES (eg changes of language such as substituting "can't" for "won't" can give clients a new sense of self-determination.) WORKING WITH BODY IMAGE When women develop bad feelings about their bodies, they often become very cut off from their bodies. They may talk about having no bodily sensations, no sexual feelings. They may describe their bodies as if they were something totally separate from themselves, and unacceptable to themselves. They may look ill at ease in their bodies, or parade them as barbie doll look-alikes. Getting some felt-sense of the body can both be therapeutic, and threatening. It is likely to release a lot of feelings. It may be useful to bear in mind the comments in the section on containment. Activities: REFLECTIONS INVOLVING BODY LANGUAGE CUES DRAWING OR WRITING THE BODY BODYWORK / BODY AWARENESS / FOCUSING (Gendlin) RELAXATION & IMAGERY TOUCH, TRUST EXERCISES, MASSAGE, PAIRED EXERCISES DANCE AND OTHER SELF EXPRESSIVE BODY WORK ISSUES FOR THE THERAPIST Because of the particular issues related to food abuse, the therapist is likely to face some dilemmas in her work. Some important considerations are listed in this section: POWER & DIRECTIVENESS: Eating problems often revolve around issues of control. The woman feels out of control around food, and fights to re-establish control through dieting. This behaviour reflects wider issues of power (and love) in the woman's life. In extreme, anything that is not understood and ordered is seen as chaotic and terrifying. In therapy, the woman may seek very rigid ways of working. An unstructured group presents both a challenge and an obstacle. Taking initiative is hard, and women often ask to be "told what to do". At the same time there may be a strong reaction against anything perceived as being imposed. In addition, many women who have problems around food have been sexually abused, and may find it very hard to say "no" to intrusions, or may even be inviting of abusive treatment. It is important that the therapist or group worker maintains a balance between offering enough support and structure to enable the woman or group to function, while giving them the opportunity to take responsibility for setting their own direction, and thus gaining some personal power. BOUNDARIES: An important part of this process is the setting of boundaries. Groups for women with eating problems are notoriously chaotic in their attendance and behaviour. Because the problem has such strong connections with boundary issues, there is a tendency for this to get played out in the group. As discussed earlier, because underlying problems are often so terrifying, it is also important for participants to have a sense of containment and safety. Starting and finishing times are important. Occasionally it will seem reasonable to run over time, but usually it is more therapeutic to stop. As a groupworker or counsellor it is easy to find oneself drawn into behaving in ways which would generally seem inappropriate. It is important to notice and reflect this rather than getting caught up in the behaviour. While it can sometimes feel cruel not to respond to pleas, overt and covert, often what is most helpful is for the worker to provide a constant point in a chaotic world, rather than to become caught up in the tide. In particular issues around touch should be considered. Touch can both be very healing and very abusive for the woman with problems relating to her body. Different therapists have their own criteria, but in this area especially it is important to be aware of motivations and of the dynamics between client and helper. Behaviour can alternate between seduction and rejection. It is also well recognised that many women who have previously been sexually abused end up being sexually abused by their helpers. SYMBOLISM AND METAPHOR: Food is a metaphor for love, eating for life, and so on. Eating behaviour is run through with metaphor and symbolism. It is my sense that at times it is helpful for the therapist to work within that metaphoric world, using the client's symbolism and its resonance with life. At other times the client seems to get caught in an unreal, symbolic world, so that it may be most helpful for the therapist to take on a grounding role. Making explicit the reality behind the myth. TREATMENT UNDER NHS Many women with eating problems never see a doctor. Those who do so receive very varied responses. Some women reach medical help, either through their own action, or the action of others, at a physical crisis point. For others the ongoing emotional strain becomes too much to manage alone. Some are reluctant, others hopeful of a magic cure. The responses will depend on the doctor's own understanding of eating problems, the severity of the physical condition the woman is in, and her willingness to co-operate. Life threatening anorexia is likely to be responded to with speed. Compulsive eating with less urgency. Either may be responded to in ways which take little account of the woman's psychological state or wishes. Treatment may be offered, if at all, in a number of ways. In some areas special units exist. In others the woman may find herself in a general psychiatric unit. There may be out-patient or in-patient services, and community psychiatric support may also be offered. Treatment may vary in style and quality. It may include physical intervention such as compulsory bed rest, drug treatments, tube feeding, restrictions on personal freedom to prevent self-induced vomiting, and jaw wiring. While these practices are viewed by some as barbaric, others see them as important in reestablishing some level of normality in a life threatening situation. Those in favour of weight gain being required before psychotherapy is offered also argue that in the case of anorexia, thinking is impaired by low weight. Also, as sexual issues often underlie the problem, the absence of sex hormones prevent useful psychotherapeutic work from taking place. Weight gain precipitates a return to a normal hormonal balance. Evidence suggests that it is important that symptoms are not treated in isolation, and that psychotherapy is offered alongside other measures. Many women approaching self-help organisations have had years of contact with the medical services. Sometimes they have nothing but praise for the help they have received. Other times they have a list of horror stories. It often seems that interventions have provoked a conflict situation in which the woman ends up in a constant battle with those trying to return her to "normality", becoming ever more devious in her attempts to out wit their efforts. This is particularly true of anorexic women. The roots of such conflicts seem to lie in the nature of the disorder itself, and are discussed in Anorexia Nervosa & Bulimia: how to help", Duker & Slade. Frequently self-help or voluntary organisations find themselves working alongside medical services. Where this happens a number of dilemmas arise. There can be concern that if a woman is receiving therapeutic help from more than one source, she may deal with inner conflicts by "splitting" her feelings, bringing one set to one situation and another set to the other. This is viewed by some as perpetuating the disorder. Another concern is whether the two agencies should communicate. While it can be tempting to do this, the loss of trust which might ensue could put the whole therapeutic process at risk. If communication takes place, it should be with the woman's agreement. A further situation which can occur is that one agency may end up in conflict with another. Here it is important to look at whether some dynamics of the woman's inner conflict is being played out between the two agencies. WORKSHOP OUTLINE FOUR THEMES, half a day to be spent exploring each FOOD: Images of food: Messages in the media: Collage, Collecting adverts Personal meanings: Drawing, Guided fantasy, Pairwork Eating patterns: Eating history over past week, day etc. Feelings about times of eating. BODY IMAGE: Images of women: Collage of magazine cuttings Looking at advertising Body awareness exercises Exploring feelings about our bodies in the present: Pair work, Drawing, Writing. Drawing body history HUNGER: Images of hunger and emptiness: Painting, Talking Guided fantasy Identifying needs and receiving nurturing within the group CHAOS & CONTROL Painting, drawing, fantasy work Boundary exercises Trust exercises READING LIST: CHERNIN, K : Womansize: The tyranny of slenderness. The Women's Press 1983 EICHENBAUM, L & ORBACH, S: Understanding Women. Penguin, 1983 EICHENBAUM, L & ORBACH, S: What do women want. Fontana, 1983 DANA, M & LAWRENCE, M: Women's Secret Disorder, a new understanding of bulimia. Grafton,1988 DICKSON, A: The Mirror Within, a new look at sexuality. Quartet, 1985 DUKER, M & SLADE, R: Anorexia Nervosa and Bulimia: How to help. Open University Press, 1988 HORNYAK, L & BAKER, E: Experiential Therapies for Eating Disorders, Guildford Press, 1989 LAWRENCE, M: The Anorexic Experience, The Women's Press, 1984 ORBACH, S: Fat is a Feminist Issue, Hamlyn, 1979 ORBACH, S: Fat is a Feminist Issue 2, Hamlyn, 1984 ORBACH, S: Hunger Strike, Faber, 1986 PASSONS, W: Gestalt Approaches in Counselling, Holt Rinehart Winston, 1975 THOMPSON, J: Body Image Disturbance, Assessment & Treatment, Pergamon, 1990 P.C.J. Brazier |