Individual psychotherapy for anorexia nervosa (original) (raw)

1985, Journal of Psychiatric Research

and the Toronto General Hospital THE careful observations and wisdom of a few modern pioneers are apparent from a review of the extensive literature on individual psychotherapy for anorexia nervosa. Although there have been other notable contributors who have shaped clinical thinking over the past decade, Bruch, Crisp and Russell have been most consistent with their penetrating formulations regarding the essential psychopathology of anorexia nervosa and have continued to provide valuable insights into the conduct of individual psychotherapy for these patients. Many of the developments over the last 10 yr have been recapitulations or refinements of their earlier observations. In describing unique psychopathological features in anorexia nervosa, they have deviated from earlier theorists who largely generalized to anorexia nervosa from constructs originally derived from another context. First this review will briefly highlight the precedence established by Bruch, Crisp and Russell and then selectively review other contributions which appear to this author to have had a recent impact on the practice of individual psychotherapy with anorexia nervosa. BRUCH (1962, 1978, 1982a) has captured the phenomenology of anorexia nervosa in which the self-starvation represents a struggle for autonomy, competence, control and selfrespect. According to this view, the mother's early failure to recognize and confirm the child's expression of independent needs has resulted in the anorexic-to-be experiencing inner confusion. Bruch has proposed a "fact finding" psychotherapy aimed at correcting specific conceptual deficits and distortions which have evolved out of faulty developmental experiences. Therapy is aimed at helping the patient discover her "genuine self"' by encouraging and confirming authentic expressions of her thoughts or feelings. Rather than exploring the symbolic significance of symptoms, experiences are re-evaluated in order to understand how conceptual disturbances, largely derived from previous relationships, have interfered with the development of autonomy and self-confidence. CRISP (1%7,1980) has provided a compelling developmental model which presumes that the central psychopathology of anorexianervosa is rooted in the biological and psychological experiences which accompany the attainment of an adult weight. According to this view, anorexia nervosa is an attempt to cope with fears and conflicts associated with psychobiological maturity. The dieting and consequent starvation become the mechanisms by which the patient regresses to a prepubertal shape, hormonal status and experience (CRISP, 1980). Crisp has repeatedly emphasized the meaning of the sub-pubertal weight in developmental terms. This model has had distinct implications for the conduct of individual psychotherapy. Renourishment evokes the developmental concerns which have been arrested by weight loss and individual therapy is directed toward creating alternative strategies for coping. RUSSELL (1970) has recognized the variable presentation of anorexia nervosa and has emphasized the morbid fear of fatness as pathonomonic. He has stressed the importance of