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.

When we speak of impulse to such and such action, of tendency to such and such behavior,of striving toward such and such goa1,or use any of these words which sound as if you, a unit, have these things in you and as if they can be studied by and for themselves, we are talking, according to the structure of our language and the habits of common speech, about something which is observably manifested as action in a situation. The situation is not any old thing, it is you and someone else integrated in a particular fashion which can be converted in the alembic of speech into a statement that "A is striving toward so and so from B."concept has been helpful in dealing with the problems that have arisen around the formation of spontaneous groups in a children's psychiatric ward. As Sullivan would say, the staff, whether nurse, attendant, or psychiatrist, becomes a participant observer (11,12).Red1 (2), Bettelheim and Sylvester (3), and others have reported upon the dynamic processes within groups of disturbed children in the preadolescent age range. Bender (4) speaks of the destructive and disintegrating effects such spontaneously formed groups may have on ward management and on the therapeutic program. The destructiveness of these groups often tends to invite their suppression by the staff. Even when suppressed, they may develop as secret or underground activities. Stewart and Axelrod ( S ) , as well as Bender (4), report efforts with group therapy programs to meet these problems. Such programs, however, in our experience, often fail to prevent such spontaneous group formations and their destructiveness.Since the opening of this children's ward in the fall of 1944, at which time there were more aggressive than neurotically inhibited children in the ward population, many spontaneous groups have been organized, often in direct opposition to the nurses and attendants. At one point in the history of this children's ward, the group members actually feared disapproval and punishment from one of its dictatorial leaders more than from the nursing staff in charge. Many efforts a t curbing such activities were tried, such as attempts to forbid organization of such groups, restriction of the privileges and even the temporary isolation of the leaders, as well as directed group therapy programs. The turnover and change of staff were constant. Sutton (6), too, experienced and reported this problem of frequent resignation of nurses on such a children's psychiatric ward.