This special issue of the Clinical Social Work Journal looks at problems in eating and body image from a twenty first century perspective. Contemporary scientific research and medical innovations have influenced current clinical theory and thinking about these complex disorders. Increasingly, we have come to recognize a fundamental link between body and mind, as well as the need for ways to integrate these interlocking systems in both assessment and treatment of individuals with eating disorders. Our clinical lens now includes advances in technology and specifically social media, which have exponentially increased the cultural domain for body image scrutiny and concomitant body shame. A paradoxical dilemma of our time is that the ability to transform our bodies through surgeries and multiple diet/exercise regimes has also exacerbated problems of self-objectification and associated body shame, commonly associated with problems in eating and body image. The current volume is made up of articles by authors with a wide range of contemporary perspectives on eating disorders and body image. Their blend of expertise and innovative thinking takes us on a journey into an extremely important aspect of eating disorders: the crucial interplay of body image and disordered eating issues.

Introducing a new feature to the journal, we begin this special issue with an interview of Susie Orbach by guest co-editor Holly Starkman. An international spokeswoman on the topic, Orbach has been influential in both professional and public arenas. Her now classic book, Fat is a Feminist Issue, opened wide the door to women’s problematic relationships to their bodies and their eating. The interview presents not only some of Orbach’s historic contributions to the field, but also her take on these dynamics today. A significant focus of Orbach’s work is her integration of psychological and cultural contexts that can thwart healthy body image development. She addresses her concerns about the pervasiveness of this link in the interview and underscores that clinicians are in a unique position to increase awareness of cultural as well as psychological influences in our work with clients.

Following the interview with Orbach are several clinically oriented articles that integrate an understanding of psychodynamics with a variety of symptom-focused interventions. The first article, “Psychodynamic Issues in the Treatment of Binge Eating: Working with Shame, Secrets, No-Entry, and False Body Defenses” is by Kathryn Zerbe, whose widely read books and articles have made a significant contribution to the field. She has long encouraged clinicians to pay attention to body image in clients with eating disorders and has been a leading voice for the value of bringing together psychodynamic and symptom-focused interventions when working with clients with these symptoms. In this article Zerbe presents two clients diagnosed with binge eating disorder who struggle with body image issues that they ignore or deny. She explores and explains how understanding defense mechanisms such as ‘no entry’ fantasies and ‘the false body’ can help a client uncover and work through split off aspects of their bodily self. She also introduces a theme that readers will find throughout this special issue: the importance of a clinician’s relationship to her or his own body and the transference and countertransference issues that may emerge, sometimes silently, but always with significant ramifications in therapy and in a client’s progress.

“Body-States, Body Image and Dissociation: When Not-Me is ‘Not-Body’” is by Jean Petrucelli, director of the Eating Disorders, Compulsions & Addictions Service at William Alanson White, author and editor of numerous important books and articles on a range of topics related to disordered eating and other compulsive and addictive behaviors. Recognizing that one of the basic reasons for eating disorder symptomatology is to manage affects that clients fear “will overwhelm them forever,” Petrucelli reminds clinicians that the eating behavior is both adaptive (it makes the feelings go away) and maladaptive (it interferes with the development of other techniques for affect management). The same need to feel nothing or to dissociate from all painful or disruptive emotions leads to what Petrucelli describes as “body image vulnerability,—an internalization of society’s notion of the thin ideal,” which in turn leads to unrealistic expectations, body dissatisfaction and a defensive dissociation from information emanating from one’s body. Petrucelli offers a clearly laid out discussion of how clinicians can understand and intervene in the closed feedback loop of eating disorders, dissociative states, and body image disturbances.

Articles by Susan Sands and F. Diane Barth, both clinicians and authors in the field, provide further compelling psychodynamic perspectives illuminated by clinical vignettes. In “Eating Disorder Treatment as a Process of Mind–Body Integration: Special Challenges for Women” Sands links negative body image and the degree of work one’s body is expected to do to regulate emotional needs. She suggests that women are more likely than men to use their bodies as a repository for overwhelming affect and that girls’ bodies are mirrored by our society in a more distorted and overstimulating manner than boys’ bodies. Therefore, she says, women tend to be more vulnerable to developing eating disorders than men. She also links body image, eating disorders and dependency issues. These ideas, as well as how a clinician might deal with them, are illustrated with clinical material.

In “Listening to Words, Hearing Feelings: Links Between Eating Disorders and Alexithymia, “this issue’s guest co-editor Barth identifies and defines the concept of “alexithymia,” or an impaired ability to use language to tolerate or process emotions, and discusses how it can impact an ED client’s sense of his or her own body. Citing research and clinical examples, Barth describes some of the issues that can emerge when alexithymia is not recognized, and offers tools for integrating techniques of affect regulation with a psychodynamic understanding to help clients begin to build the capacity to use their words to manage their feelings, including their bodily sensations and body image.

In “The Intersubjective Experience of the Physical Body in the Clinical Setting of Eating Disorders” Suzanne Daly further explores the role of a clinician’s relationship to her own body as a client struggles with issues about body image not only intrapsychically, but also within the context of transference and countertransference issues. This article looks at questions of self-disclosure as it relates to the inescapable presence of both a client’s and a female clinician’s bodies in treatment, and ways that a female clinician can use discussions of her physical body as part of the clinical work with a female client with an eating disorder.

In the next two articles we look at group and family therapy as a way of helping clients with eating disorders deal with both the symptoms of the disorder and the problematic body image that often accompanies these symptoms.

Guest co-editor Holly Starkman presents an integrative group treatment model that incorporates mindfulness principles and feminist relational-cultural theory within a psychodynamic-oriented framework. In her article, “An Integrative Group Treatment Model for Women with Binge Eating Disorder: Mind, Body and Self in Connection” Starkman presents the group model based on her extensive clinical experience with women who have had long-term binge eating and body image problems. The integrative approach emphasizes a biopsychosocial perspective that the author has found useful for assessing and treating the complex problems of mind, body and self-regulation characteristic of the disorder. An integration of mindfulness principles and skills is presented through group narrative examples illustrating the clinical utility of the interventions.

In “Two Case Studies on Family Work with Eating Disorders and Body Image Issues” co-authors Fran Gerstein and Frani Pollack discuss the significance of family therapy for addressing underlying systemic factors that may not have been revealed in an individual treatment for problems in eating and body image. Gerstein and Pollack highlight creative ways that a family therapist can address dysfunctional family patterns that contribute to an eating disorder. In discussing some of the early family therapy pioneers, the authors emphasize the relevance of those models in contemporary clinical treatment. The two case studies presented illuminate specific family therapy techniques for addressing body image and eating problems while illustrating clinical use of the models discussed.

Shifting the prism slightly, Johannes Jungbauer, Jessica Helbach and Karl Urban offer insight into the siblings of ED clients in “Experiences, Burdens, and Support Needs in Siblings of Girls and Women with Anorexia Nervosa: Results from a Qualitative Interview Study.” Calling these family members “the forgotten kin,” and noting their vulnerability to developing eating disorders, this article offers results of interviews designed to investigate siblings’ experiences, burdens, and support needs in a differentiated manner. Based on the results of the study, the authors make a variety of concrete recommendations for psycho-social practice, such as the inclusion of siblings in treatment settings, as well as the idea of providing specific forms of support for siblings of anorexic women and girls in different age groups.

In their article, “Exploring Body Dissatisfaction and the Relevance of Religiosity: A Focus on ultra-Orthodox Jews in a Community Study of Adult Women,” Marjorie Feinson and Tzipi Hornik-Lurie provide a transition from family to social environment. In this population-based study of body image issues among diverse groups of adult Jewish women in Israel, we learn about some significant indicators of body dissatisfaction found within this group. The authors investigated the relevance of religiosity and inquired about possible protective factors for body dissatisfaction among a cross-section of Jewish women. An intriguing examination on the potential influences of religious traditions and values on body dissatisfaction is presented along with discussion on the clinical application of significant findings from the study.

We then turn to the growing and until recently largely neglected issue of men with eating disorders. We feel quite fortunate to have contributions by several well-established and well-respected authors and researchers in this area.

The next article addresses some of the complexities of gender and the distinct treatment issues among men with an eating disorder. Author Douglas Bunnell is the Clinical Director of Monte Nido and has been a longstanding leader and advocate for individuals with an eating disorder and their families. His article, “Gender Socialization, Countertransference and the Treatment of Men with Eating Disorders,” points out that, while both men and women evidence similar symptoms and behaviors, gender socialization factors for men play an important role in the treatment relationship. The article considers the detection and communication of gender-based countertransference reactions to be a significant and underexplored dimension in the treatment of these disorders. Bunnell posits that incorporating pertinent gender socialization factors in psychotherapy can allow for a more in-depth exploration of a male client’s self-perception, body image and associated behaviors. This article examines several compelling aspects of treatment with male clients and gender-based countertransference reactions with clinical examples that highlight the discussion.

Nicholas Lanzieri and Tom Hildebrandt bring years of research to their article, “Using Objectification Theory to Examine the Effects of Media on Gay Male Body Image,” examining the effects of media on gay male body image through the theoretical lenses of social comparison, objectification and consumer commodity fetishism. Citing research that gay male adults are more at risk for developing body image dissatisfaction than other male populations, they also note that these body image difficulties have been connected to the development of disordered eating patterns. They then hone in on studies that link these issues to media genres that propagate idealized, unrealistic images of male physiques. The article considers ways that theories of social comparison, objectification, and consumer commodity fetishism can help clinicians understand how and why media imagery may be internalized by gay men and how such internalizations harmfully impact their body image.

In “Eating disorders and Body Image Concerns Among Male Athletes,” Lisa DeFeciani looks at several psychosocial and gender-related factors associated with the development of body image disturbances among male athletes. DeFeciani provides a thoughtful discussion on several treatment issues specific to male athletes with corresponding in-depth case examples that illustrate her clinical viewpoints. Lisa DeFeciani, in agreement with other contributing authors to this issue, underscores the importance of addressing the distinct assessment and treatment needs of males with eating and body image problems.

Conclusion

While eating disorders and body image issues have received significant clinical and empirical inquiry over the past four decades, many questions about the complexities of these problems remain unanswered. What we do know is that negative body image is inextricably linked to eating disorders and the papers presented in this issue discuss some of the myriad ways that relationship is evident. The articles in this special issue each add something to a discussion that is just beginning. With the impact of social media, technology and cultural demands for a universal “perfect” body, there is now, more than ever, a need for clinicians to understand the interplay of culture, psyche, body and mind in the development, maintenance and treatment of these symptoms in an ever-increasing client population. Each of the contributions included in this issue offers thoughtful clinical and theoretical insights on these issues.