Return to:
News and Views
Reviews: Books
The Golden Cage
By Hilde Bruch, M.D. Cambridge: Harvard University Press, 2001, 150 pages, $16.95 (paperback).
The Golden Cage provides an insider’s look into the stories, experiences, and emotions of the young men and women affected by anorexia nervosa. Written in language that is very accessible to patients, parents, and mental health professionals, this book can be understood and utilized by adolescents and adults involved in the treatment process. Hilde Bruch realized the importance of understanding this illness from the viewpoint of her patients. She makes clear that weight gain in patients should be incorporated into a more comprehensive treatment approach that improves the body and mind of the individual. In this way, she instructs her audience (parents, patients, psychiatric professionals) that “in spite of outer appearances this is not an illness of weight and appetite-the essential problem relates to inner doubts and lack of self-confidence,” (p. 93). In bibliotherapy, these concepts are extremely important to reinforce and explore with the patient in greater depth and detail. Still, Bruch emphasizes that the nutrition of the patient must be improved for any productive psychotherapy to take place. Starvation markedly interferes with the normal psychological functioning of the patient; thus, any type of typical psychotherapy will be undermined by reactions governed by the state of starvation. Consequently, this book encourages parents and mental health professionals to satisfy basic biological needs first, so that psychotherapy can be more efficient and effective.
Another important aspect of anorexia addressed in the book is the portrait of the patient. Parents and educators alike stress the characteristic good behavior, academic excellence, and conscientiousness that describe children before the development of their anorexia. At the same time, the descriptions and stories of Bruch’s patients paint a very different picture of girls who live in “continuous fear of not being loved and acknowledged,” (p. 53). While externally these young women are given every opportunity and advantage in life, they also feel undeserving and burdened by the many privileges handed to them. In bibliotherapy, these descriptions and stories can be used as a tool for therapists to normalize the feelings of inadequacy and guilt a patient might feel. For parents too, Bruch’s stories may help them better understand how the privileged lifestyle they’ve provided for their anorexic child may have contributed to the illness. Bruch elucidates in her many stories of anorexics with the “perfect childhood” that a child never giving any trouble should be red flagged for developing an eating disorder; “the overconscientious, overstudious, and compliant performance is a warning sign of something wrong” (p. 56).
Further, using this book might be helpful in the beginning of treatment so that the anorexic patient can connect to others who feel and think like they do. Bruch makes it clear that the initial phases of treatment are the most difficult times in psychotherapy because patients are resistant to any type of authority. Thus, after adequate nutrition has been established, using this book in bibliotherapy might be helpful in initiating discussion between therapist and patient, or connecting stories or feelings that relate to the patient. In addition, many anorexics often have trouble articulating their experience and emotions after living in a state of starvation for an extended period of time. In reading about the experiences of others and how it relates to them, anorexic patients may feel more comfortable and ready to tell their own story. One of the main challenges in treating anorexia is that many patients feel like no one understands them or what they are going through. Through bibliotherapy, this book has the capacity to bridge the gap between patient and therapist in understanding the patient’s disorder and encourage the patient to place trust in mental health professionals that they will listen and help them get better. Furthermore, using this book with recovering patients may also be helpful in relating to others who have gone through the same struggles and setbacks as they have.
Also, this book is clearly an invaluable resource for parents and caretakers who bring in anorexic patients for treatment. In helping parents better understand the roots of the disorder and the personal experiences of those who have suffered through it, this book emphasizes that parents should not blame their loved one in treatment for having anorexia. Further, the many inspiration stories told through the eyes of Bruch’s clients may give parents hope that their child will go on to live a normal life despite their current condition.
At the same time however, this book may not be a wise choice for patients who have not undergone some nutritional improvement. In contrast, this book may have adverse consequences in perpetuating the illness by giving patients ideas to continue its progression. Bruch stresses throughout the book that it is nearly impossible to engage in any type of psychotherapy until the psychological effects of starvation have subsided. She emphasizes that many patients’ detrimental treatment experiences not only exacerbate the disorder but increase the likelihood of severe relapse. Consequently, use of this book in treatment must be based upon the conscientious and thoughtful decision of the primary care physician or psychotherapist that their patient is mentally and physically ready for change.
Despite the many strengths of this book, Bruch fails to mention the influence of pop culture and the media in perpetuating anorexia. She does not point out the impact the entertainment industry has on promoting anorexic actors and actresses who epitomize American success and opportunity. She does not emphasize that these too-thin starlets are supposed to act as role models for today’s youth, that their inability to do so in a physically healthy way distorts young girls’ perception of weight and beauty. Another weakness of the book comes not out of any deficit of the author, but rather the fact that the face of anorexia has changed over time. Today, it is clear that anorexia has no color, race, or socioeconomic background. While this book overwhelmingly describes this illness in a white, upper class, privileged context, this model no longer holds true. It is clear that in order to develop a more thorough understanding of this disorder, culture, ethnicity, and socioeconomic variables must be taken into account.
As in 1978 when this book was written, thinness still represents a disciplined sense of self-control and superiority many young women strive to achieve. As described so perfectly by Cathrine Steiner-Adler, Ed.D., author of the book’s Foreword: “Thinness seemed to replace virginity as the key to feminine value, and the assessment of a woman’s moral character [has] shifted from when she was sexually active to what she ate” (p. xii). In future editions of this book, it may be helpful to create a space for these new faces of anorexia to tell their story. Until then, The Golden Cage should continue to be used in bibliotherapy for patients, parents, and other mental health professionals working in anorexia treatment programs; not only does it capture the many intimate moments, thoughts and feelings anorexic patients don’t realize or can’t admit, but it also may help parents understand the many layers of the illness more effectively.