Department of Applied Psychology, University of Portsmouth, King Henry Building, King Henry 1 Street, Portsmouth PO1 2DY, England
Received date: January 20, 2016; Accepted date: February 18, 2016; Published date: February 27, 2016
Citation: Thomson W (2016) The Power behind Fragility Anorexia: A Case Study. J Psychol Psychother 6:242 doi:10.4172/2161-0487.1000242
Copyright: © 2016 Thomson W This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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The referral came via the General practitioner: A girl of seventeen: Kate1 had anorexia nervosa her weight was under seven stone and falling. As the consultant psychiatrist passed me the file he said he was going on holiday and that he’d like her weight to improve before he returned. I didn’t know why the patient - Kate hadn’t been referred before if she was so ill or why she wasn’t in hospital? I suspected the family were resistant to outside intervention as is often the case.
I rang the number on the referral letter and the mother answered. I introduced myself and asked her if I could make an appointment to see the family together. She seemed hesitant and nervous and even more so when I asked if I could see the family preferably sitting round together during my first visit. She said she’d see what she could do. I arrived at the address of a very nice house in a quiet country village. The mother answered the door and invited me in. Her eyes said it all: she looked slightly unkempt worried and weary. As I entered the living room, first impressions were of a very disunited anti-family group. The family consisted of three girls with ages from twenty one the eldest who was at college, a nineteen year old at university and the youngest seventeen: Kate - the patient attending school. All the girls were still living at home with their middle aged parents.
In contrast with the mother the rest of the family were acting in a very uncooperative even rude manner. The mother was clearly embarrassed by their behaviour. I introduced myself and I suggested we sit round the table. They all showed their reluctance moving to the table slowly and making noises to show how uncooperative they were. The intention was obvious a united attempt to make me feel as uncomfortable as possible. I began by suggesting they introduce themselves and then for each family member to tell us their thoughts. The father began by saying he had better things to do with his time, followed by the two older girls agreeing with him. The mother was by this time crying and distraught: she disclosed how despite her best endeavours to provide tasty food the anorexic daughter - Kate just moved the food around on her plate with a fork and was still losing weight! Kate sat hunched in a large jumper hugging her knees, emaciated, and detached, with a noticeable blue tinge round her lips. Nobody appeared to be concerned by Kate’s condition or by the outpouring and the obvious desperation and misery of the mother who was left uncomforted and sobbing. They were dissociating themselves from the seriousness of the situation.
The older sister’s blurted out that she wanted to leave home as soon as she could, and that she had had enough, her younger sister agreed. The older sister said she was fed up with sitting round the table for a meal and going through the same painful procedure having to witness Kate rejecting food. She resented the time her mother spent shopping, cooking, worrying, and pandering to Kate. The mother interjected and said what else could she do see her daughter die from starvation? Kate sat seemingly impervious and unmoved by this outpouring. The second daughter said how they used to always enjoy meal times and that their mother was a very good cook and now it was an experience that no one enjoyed. They were no longer a family they would all prefer to go to MacDonald’s or get fish and chips and eat away from home.
Between the four walls of the house there was a lot of suffering and I needed to locate the cause, however time was not on my side clearly Kate was deteriorating rapidly.
I was pleased that I could experience the transference by feeling, hearing and witnessing the extent of the hostility and resentment towards me but particularly towards the mother. They were all fed up with the control Kate was exerting on the family it had been going on for months previously. As I listened I knew that they were right it had gone on a long time - too long. This was a sick family. Although the resentment was centred around food I knew this was not the real issue. My task was to bring about change to this much disunited family as soon as possible. The only enduring relationship was built on the duty which existed between the mother and Kate but this was one - sided. I realised that this was the only opportunity I would have to see the family together again. So I had to do something which would appeal to them all, but which included Kate.
I digress: When I worked in the Misericordia hospital in Canada years previously, I had to give passive movements to two women who hadn’t recovered from the anaesthetic during surgery. It was an odd experience: they were lying in private rooms intubated and unconscious waiting to recover consciousness. I would quietly carry out the daily procedure of moving their joints in readiness for them should they regain consciousness. I’d look at their faces and watch for them to frown indicating that perhaps a joint might be stiff or painful, wondering what was going on and hoping they would recover. Sometimes a nurse would come in and feed them via the tube. On one occasion I asked her what they were fed with? She told me it was a particular product which contained everything necessary to keep them healthy: All the protein, minerals, and vitamins they needed. And they did look healthy: their hair, nails and skin were obviously in the very good condition.
As I sat round the table amidst the hostility and looked at Kate I thought back to my experience in Canada. Kate was too ill to engage in rational discussion and gaining her trust would have taken time which wasn’t an option considering the seriousness of her condition. I saw that the meal times were an essential part of the cohesiveness of the family and that since Kate wasn’t eating she could be excused from mealtimes. Providing that she drank the product I’d discovered in Canada. It was readily available in chemist shops and I knew it would provide her with the nutrients she needed to keep her alive.
I addressed the mother with my proposal with the family listening: she was to stop her vigil in the kitchen and resume cooking for the family as she had done previously. I assured them all, the drink would provide Kate with enough to sustain her. Kate was reluctant so I emphasised that seeing that she was still drinking it would only take a minute to take the prescribed drink four times a day. The advantage to her was that she wouldn’t have to struggle to eat at all. I needed to get them all to agree including Kate. The plan was for her mother to mix the drink and watch Kate drink it. The family seemed to agree and approved the proposal and I left saying I would return.
The next day I went to see the school where Kate was studying for her A levels. They were frightened by the seriousness and possible consequences of her condition, it was having a negative effect on the other children in Kate’s class. They were worried in case the other children, acceptably boisterous at times, should knock into her. They too were going to extreme lengths to protect her and to ensure Kate could sit the exams on time. She had stopped partaking in some classes, and was provided with a taxi to school because she was so frail.
Two days later I returned to see the mother alone, she appeared pleased to see me. I could see a slight change in her and she reported that Kate was drinking the nutriment drink although reluctantly. She readily discussed the family and elaborated on Kate’s condition which she told me had deteriorated over a number of months. She explained that Kate had been a girl guide and now was a rover where she had participated in expeditions and camping which she enjoyed. But she had given it up now because of her fragility: namely because of the risk of permanent damage to her heart and bones - osteoporosis. She had developed downy hair all over her body, her periods had stopped four months previously, etc.
She was pleased to tell me how the rest of the family were now sitting round the table eating the meals she was preparing. On that occasion I did not feel it appropriate to pry and ask her about her relationship with her husband I just relied on her to tell me what she felt she wanted to.
I didn’t know anything about causation but several motives occurred to me. Could it be Kate was afraid of impending woman hood and university? Or was it the fear that this seemingly close - knit family appeared to be breaking up with the possibility of the older sisters moving away from home? I also knew Kate’s illness in itself would have affected the relationship between her parents. Was there any infidelity on the part of the father which Kate had intuitively suspected which had triggered the anorexia? Or was Kate unconsciously trying to prevent them breaking up by uniting them with the concern of her illness?
I sensed the mother had indulged her family to her own detriment. So I asked her about her own aspirations. She said she didn’t have any - she was too busy with the family. I pointed out that she deserved more and that the girls would probably be leaving home and that she should look forward to her own future. I suggested she should go to the library and investigate possible careers and that we would discuss the options on my next visit. It was giving her permission to indulge in herself.
In the meantime I was making progress with Kate. Because she was better nourished she was feeling better and did not look so transparent. I saw her condition as a symptom of turmoil and did not collude with the symptomatology of anorexia, such as discussing food, or weighing her. What was now happening was a change in the family dynamics away from the preoccupation with cooking, shopping, and miserable mealtimes. Kate had now lost some of the control she had had. Previously the family had gradually become involved in and held to ransom and manipulated. Kate needed to have the power she had exerted over the family taken from her. She had demonstrated that she couldn’t survive if she continued. But neither could her family survive if the situation had been allowed to persist.
I revisited the school and gave the appropriate support to the staff that once again was in a similar position to the mother, very fearful if Kate were to die.
The changes had to be almost imperceptible to Kate who had been in an exalted position. I did not want to progress too quickly so that she felt she was relinquishing the ground she had made and regret it by relapsing. It was a case of replacing the anorexia with achievement’s which ensured her future without her losing face.
The mother was relishing the prospects of a career and her daughters were encouraging her to study for the exams which she would need if she became a teacher. When I called and they were together they laughed about their mother becoming a student, but they helped her with typing, applications, and homework. They all saw the funny side and teased her, but they were also very respective and proud of her. She wanted eventually to study speech therapy. It was so good to see that she was earning the respect she deserved by all the family including her husband.
Kate was obviously better but at no time did I feel it appropriate to weigh her nevertheless I did wonder what her weight was.
The general practitioner was kept informed by letter and he decided to ask her to ‘jump on the scales’ she had put on two kilos. She took her exams and passed well and we continued to meet and discuss how she felt and about everything: boyfriends and the future. She was now allowed to sit round the table with the family as long as she ate. With support she gradually improved and didn’t relapse, which I was afraid was a possibility given the antecedents of the case.
Two years later I was travelling on a train to London and walking through the carriage was Kate’s mother she spotted me but I didn’t recognise her - she looked radiant! She asked me if she could blow her own trumpet? She told me she was on her way to an interview as a speech therapist. Kate was at University.
As a therapist but new to family therapy this was my first case involving anorexia. I did not view it, perhaps naively, any differently to any other referred case. Key to my involvement was intuition, feeling, witnessing, and thinking it through on that first visit, and seeing where the power lay. Where my involvement did differ was in the recognition that Kate’s condition was physical and mental, and as I explained I did not have time on my side. In this case the family behaviour and that of the school had become entrenched and was leading to rapid deterioration, the situation needed to be radical and managed. To put a grand title on my intervention it was a biopsychosocial approach. My experience as a mother, as a physical therapist, and then as a family therapist quite naturally suggested to me that if my patients have maybe a drug, or drink related, or in this case eating disorder my first thought is to question are they in sufficient health to concentrate, and engage with what I had to offer. My only resource was myself. Hence my biopsychosocial approach.
My concern was for the whole family, the assumption was that they were all under - functioning and miserable. This was serious particularly as the individual futures of all the girls and the choices they made may have been influenced by the circumstances they were now caught up in. My treatment strategy in general relied on assessing each case differently and formulating a strategy to change the family dynamics. Underlying this particular case was the power Kate exerted by exercising the ultimate outcome: death. I needed to take away that power from Kate and then gradually relinquish it from me back to the family to the school and to Kate. The school and family from being impotent and colluding in the psychopathology needed to learn. It was an education for the school staff, to their credit they embraced the situation and came out trump’s as did the family.