Anorexia nervosa and the psychotherapeutic hospital

This paper illustrates psychoanalytically oriented psychotherapeutic work with persons suffering from severe anorexia nervosa who reside in a psychotherapeutic hospital. Anorexia nervosa in its more drastic forms is here viewed as a circumscribed or "spot" manifestation of borderline and schizophrenic pathology; thus these observations also fall within the framework of the psychotherapeutically committed hospital treatment of a wider range of other severe disorders. An exposition of the following elements is included: (1) individual psychoanalytically informed therapy in a therapeutically conceived milieu; (2) firm encouragement to gain weight and modify vomiting by collaborative and voluntary means, if possible, with emphasis on clarifying the contractual boundaries of responsibility; (3) encouragement of the therapeutic alliance and deemphasis of a static symptom-centered approach; (4) coordinated nursing, medical, laboratory, and dietary staffs in an integrative "holding environment;" (5) limited use of pharmacotherapy, with attention focused consistently on the interactional meanings of prescribed medication; (6) physical separation of patient from family. An integrated framework for addressing and pursuing the multiple issues, dimensions, and layerings inherent in intensive psychotherapy with severely anorexic patients in an open hospital environment is presented and is intended as a paradigm for the treatment of other severe disorders.