Hilde Bruch: 'a sparrow in a golden cage'
Bruch developed her aetiological model of anorexia nervosa as the child becoming involved with her family in such a way that she fails to achieve a sense of independence. Thus a paralysing sense of ineffectiveness pervades all her thinking and activities. Bruch used this model to provide an entry into the psychotherapy. She engaged her patient in a dialogue which became central for the resolution of her conflicts. Patients are often receptive and reassured when the therapist does not criticize them for behaviours associated with their illness. They may even obtain a relief from the implication that in some way the families are to blame for the anorexia nervosa. Using this model the therapist will engage his patient in the therapeutic metaphor in which she is seen as 'a sparrow in a golden cage'. She is then encouraged to think of ways of fulfilling her own needs and desires, rather than relying on others, and seek an autonomy that frees her from the tyranny of anorexia nervosa/2.5)
Crisp's model of anorexia nervosa as a flight from growth
Crisp has explained in detail how the programme of treatment is based on his model of anorexia nervosa as a refuge from puberty which the patient has found overwhelming. The youngster reverses her pubertal development by limiting her intake of food. (12Z,128) His treatment initially involves an intensive inpatient programme lasting 10 to 12 weeks followed by outpatient treatment for up to 6 years. The advantage of this extensive programme is that it enables the patient to accept gradually an increase in weight while facing up to the feelings of panic and helplessness that originally led her to arrest her puberty through self-starvation. This interpretation is presented to the patient and to her family so that they come to see the psychotherapy as a way of solving the problems.
The model is a useful one even within a more limited outpatient psychotherapeutic setting. Some patients will readily identify their distress when overwhelmed by powerful sexual feelings or when confronted with personal and social responsibilities perceived as the result of growing up. The aims of the psychotherapy are to support the patient while she is beginning to abandon the psychobiological regression of anorexia nervosa. In addition she is encouraged to broaden her perception of herself in ways that are no longer wholly dependent on her physical appearance but include an improved sense of competence and self-esteem. She is helped to tackle personal and social problems from which she had previously escaped so that she can address her own and her parents' concerns about sexuality.
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