years psychiatrists have recognized that there is a type of emotional dissence from school. This is a deep-seated psychoneurotic disorder fairly sharply differentiated from the more frequent and common delinquent variety of school truancy. The syndrome, often referred to as "school phobia," is recognizable by the in ense terror associated with being a t school. The child may be absent for Broadwin, Isra T. A Conhidwion to the Study d Truancy. Au. J. OUTHOPSYCHIATUY, 11.3.1932.Fo" turbance in children, associated with great anxiety, that leads to serious ab-per1 -d s of weeks or months or years, unless treatment is instituted. The children,

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N THIS paper we shall present a report of our experiences in working I with a 13;-year-old girl who alternated between overweight and cachexia.We hope that, by reviewing the first twenty months of therapy with this adolescent girl and both her parents, we may contribute in some way to a further understanding of the intrafamilial nature of conflicts which may be expressed in the symptoms of a child, and of the meaning of starvation and overeating. This review will perhaps also serve to illustrate both the possibilities and the difficulties inherent in collaborative psychotherapy.Since we are concerned here with aspects of anorexia nervosa and obesity, we have surveyed the literature on both subjects. One is at once struck by the ways in which, as reported, the two are alike. The family milieu and the character of the parents, as well as the developmental and past histories of the patients whose cases have been recorded, are strikingly similar. T h e psychopathology, as enunciated by some authors, is also almost identical in both conditions. We shall present a brief summary of the findings in the literature.Rynearson and Gastineau (l), in their recent book on obesity, surveyed the literature comprehensively and concluded that there was no evidence for endocrine, metabolic, constitutional or hereditary factors of prime importance in obesity. Dr. Rynearson has been heard to say, "The only glands involved in obesity are the salivary glands." They point out that their experience agrees with that of most internists and students of obesity that excess food intake and lack of exercise are the important factors in producing obese individuals (2).Shick ( 3 ) believes that there is evidence for constitutional factors in obesity. H e quotes Freud's statement that psychologic experiences of the child are registered on an organism with a certain constitutional endowment, and believes that individuals have tendencies toward obesity.Bruch (4), in her extensive work with obese children, has found little evidence for disturbed physiology as a cause of obesity. Most authors agree that the most important single cause for overweight is excessive eating.The pathological physiology of anorexia nervosa has only recently been proved to be the effect and not the cause of the disorder. The clinical pictures of anorexia nervosa and Simmonds' disease (pituitary cachexia) ap-387 This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

HE dynamics of individual therapy; i.e., the processes in the situation T of a therapist and child, has received much attention, thought, and experimentation. Group therapy; that is, the situation of several patients and one therapist, has similarly been the subject of an increasing number of studies and clinical efforts.At a recent psychiatric meeting1 there was a round table discussion on a topic entitled, "The Psychodynamics of Residential Treatment of Children." During this discussion several participants suggested that in addition to direct individual treatment in play or interview sessions with the child, and in addition to concomitant therapy of the parents, there was much to be learned about what went on between other adults and children in a residential treatment center or psychiatric hospital ward for children.It was suggested that the counselors, nurses, and attendants in such situations might constitute, by virtue of the time they spent with such patients and by virtue of the care they gave to them, a valuable therapeutic resource. Perhaps still too frequently, for various reasons avoidable and unavoidable, that part of the staff personnel which has most personal contact with the hospitalized psychiatric patient has not participated as fully2 as it might in clinical conferences or informal discussions with supervising and resident psychiatrists and other professional members of staff. Their recorded observations of the behavia-of patients and their technical assistance in medical procedures and custodial functions have long been utilized, or at least required. The extent to which personnel attitudes affect the patient's emotional state is a matter of general clinical experience3 even outside a psychiatric ward or hospital. The deliberate use of the relationship between patient and nurse by the physician for therapeutic purposes is probably as old as the art of nursing. But its frank acknowledgment as a therapeutic adjunct in psYchiatric literature4 and discussions, and the study of its dynamics and r e k * Presented a t the 1947 Annual Meeting.Meeting of the American Psychiatric Association, Chicago, May 194.6. Rowland (1) and (2) describes the relatively closed caste system characteristic of the social strucNre of a mental hospital employees, emphasizing in particular the closer contact of the nurses and attendants with patients. There is also discussion of types of interaction processes and of prevalent attitudes of conflict between these staff members and the patients.Kimber ( 5 ) places stress on the importance of psychiatric nursing as the treatment needed by most hospitalized psychiatric patients.Reichert (3), in addition to Kimber, are among the few psychiatrists who call attention to the therapeutic possibilities of the attendant-patient and nurse-patient relationship. From personal communication the writer is aware that Sylvester and Bettelheim a t the Orthogenic School, Chicago, are a'so interested in this problem. See also (7) and (6).

HIS paper describes a technique for psychiatric treatment and research in T the behavior problems and psychoneurotic disorders of children in which concomitant therapeutic efforts are made by two psychiatrists, one of whom deals with the significant parent and the other directly with the child. Although the rationale of the approach has been indicated by Lowrey (I), and a t times even explicitly stated in the literature by Almena Dawley (2), Greig (3), Anna