Abstract
This is a masterly work, a must read for every psychiatry trainee and every would-be psychotherapist. In fact, anyone who is engaged in this precarious meld of science and art would be well advised to peruse David Malan's book carefully and to ponder the issues raised. All of us who have agonised over the problems of anorexia nervosa, dangerousness and suidicidality and the practical dilemmas these pose for the psychotherapeutic relationship will find this book difficult to put down.
The contents consist quite simply of the histories of three patients, all young adults when we first meet them: a woman physically recovering from anorexia nervosa; a man with murderous sexual fantasies; and another who attempts suicide. The author reports on 20–30 years of follow-up for each, discussing their progress and their movements towards healing in the most succinct yet erudite manner. He neatly dissects the therapeutic underpinnings of each case and relates it to the literature. Unwieldy as the latter is on the psychodynamics of managing anorexia nervosa, homicidal fantasies and suicide, it is nicely synthesised then applied elegantly to each case. The literature is thoroughly reviewed and comprehensively referenced.
The writer/therapist carefully describes the initial assessment and the first psychotherapeutic phase of treatment. He discusses his interpretations and interventions, frankly examining the shortcomings of his own technique and looking at its interface with other therapies. The patients are followed through various treatment modalities including psychiatric hospitalisation, primal scream, re-birthing, therapeutic communities, behaviour therapy and medication, always with the broadest and most commonsense perspective. Remarkably, the author maintains contact with the patients over such an extended time frame and continues to examine the repercussions of the therapeutic process throughout. Perhaps the most intriguing part is the discussion of the patients' healing processes, what helped and what didn't. The patients' strengths and resourcefulness are always allowed to shine through and the therapist never presumes to usurp centre stage.
With respect to working with the patient suffering from anorexia nervosa, David Malan describes what is clearly an interpretive technique yet he quotes freely from the work of Hilde Bruch, which is Kohutian in essence and thus non-interpretive in application. Interestingly, he does not address this issue per se but obviously finds much in Bruch's approach which is akin to his own. Here and elsewhere he never labours points of therapeutic dogma, but instead lets the psychodynamics clearly emerge through his interchanges with the patients, their histories, their letters and their self-reflections; he allows the patients to speak for themselves. The reader feels privileged to know these people and inspired by their journeys. Herein lies the mastery.