Paradox, persecution and the double game: psychotherapy in anorexia nervosa

Harm minimization in severe and enduring anorexia nervosa

For many sufferers of anorexia nervosa, the time course is long, and the prospect of disability and family burden great. This is all too often the case, even with early diagnosis and treatment. The term severe and enduring anorexia nervosa has been applied to these survivors. Yet, a majority of patients do eventually recover and, even where this is not the case, adaptive medical stability and function can be maintained despite alarming dilapidation. Managing the years of illness so as to have the best outcome physically and psychologically, even where full weight recovery does not occur, or has not yet occurred, is the topic of this article. Literature pertaining to harm minimization in chronic, severe, enduring, and long-standing anorexia nervosa was selectively reviewed using an Ovid data base and Google Scholar. The authors' own clinical experience over almost four decades in public and private hospital and community settings has also informed much of what has been written. The authors would like to think that it is possible to do better than the familiar injunction (variously attributed to Hippocrates, Galen, and others) of 'primum non nocere'-although this is a good place to start.

Compulsory treatment in eating disorders: Control, provocation, and the coercion paradox

In eating disorders, the denial of the illness is a central phenomenon. In the most severe forms of anorexia, compulsory treatment may be necessary. The professional acceptance of involuntary treatment is controversial due to the fact that the autonomy of the patient is juxtaposed with the obligation of the health care practitioner to save lives. This paper discusses the major practical and ethical considerations surrounding this controversy. In addition, case vignettes are used to illustrate various strategies to diminish client resistance and enhance motivation toward treatment. Involving the family is nearly always essential for the treatment of patients with eating disorders. In some cases, parental consultation (i.e., treatment without the client) can also be an option. Home visits, though rarely used, can reframe the therapeutic relationship and provide information about family functioning. In general, a lower level of treatment coercion can be achieved through transparent client-parent and client-therapist communication.

The Egosyntonic Nature of Anorexia: An Impediment to Recovery in Anorexia Nervosa Treatment

A serious problem faced by clinicians treating anorexia nervosa is the egosyntonic nature of the illness, wherein individuals with anorexia nervosa value their disorder, thereby hindering motivation for recovery and engagement with treatment. The objective of this review article is to elucidate the nature of egosyntonicity in anorexia nervosa, reviewing both qualitative and quantitative research pertaining to this topic, and, importantly, to present methods to overcome this impediment to recovery in anorexia nervosa treatment. The authors elucidate functions of anorexia nervosa for patients, both within psychological and social spheres, as well as highlight the detrimental effect of egosyntonicity in terms of illness severity and motivation for recovery. The final part of the paper contains suggestions as to methods of bypassing pitfalls linked with the influence of the egosyntonic nature of anorexia nervosa within a treatment setting, as well as an examination of three current treatments (enhanced cognitive-behavioral therapy for eating disorders, Maudsley Model of Anorexia Nervosa Treatment for Adults, and Specialist Supportive Clinical Management) in terms of the degree to which they target egosyntonicity.

Towards a psyche for psychiatry

OBJECTIVE

To draw attention to the absence of a concept of personal existence in standard psychiatric approaches to mental illness.

METHOD

To sketch a shift in Western consciousness which occurred suddenly before World War I, involving a banishment of such notions as self and the awareness of inner life from the discourse of psychiatry, psychology and philosophy, leaving a fundamental vacancy at the heart of these disciplines.

RESULTS AND CONCLUSION

The positivist-behaviourist hegemony of the twentieth century involved an implicit devaluation of that which is essentially human. The influence of this tradition brings with it the risk of an understanding and treatment of mental illness which leaves out issues at the core of humanity. I suggest we need to recover something of the manner of thinking of the great figures in psychological thought who were writing before the rise of behaviourism and who were contributing to the origins of dynamic psychiatry. A study of the phenomena of human consciousness was central to their work. Main figures mentioned include: Hughlings Jackson, the great neurologist who considered a career in philosophy; Pierre Janet, a philosopher turned psychiatrist; and William James, a physiologist who became a psychologist and philosopher.