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The material offered is a very full account of one session in the ongoing psychotherapy of a young woman trying to recover from an eating disorder, with a history that suggests her relatively recent bulimia may be symptomatic of some fundamental internal difficulties. Despite the often tender therapeutic alliance between the therapist and patient and the regular references to their previous shared understandings about her state of mind, I found myself, on initial reading, somewhat depressed in reflecting on the intractability of this sort of mental constellation and of eating disorders generally. Whilst the therapist's background notes record significant psychological gains, including the patient's acknowledgement of the connection between her physical behaviour and her relationships and an improvement in her attendance, potentially productive exchanges between the two are repeatedly
thwarted. I was left with the sense that for every step forward there was likely to be at least one step backward, with slow progress incremental and unstable, and wondered if a countertransference response similar to my own had fuelled the therapist's annoyance at the patient's announcement of her holiday plans. The unspoken exclamation “You're your own worst enemy!”
Perhaps a sense of frustration and puzzlement about Anna's persistent capacity to erode the gains she makes also prompted the therapist to offer this account for professional scrutiny in the hope that some additional input might help something shift. Although Anna's functionality has clearly improved greatly since her need for an inpatient stay, evidenced by her academic success, by a sexual relationship with someone she describes as “normal” and by her ability to make plans for work and leisure, her mental life remains dominated by corrosive anxieties that result in self-sabotage. The story of her job interview is a pertinent example and painful to read: Anna's panic sets in train a series of unfortunate mental events t