Intensive Structural Therapy

Patient Details:

21-year-old woman

Presenting problems:

• Compulsions and anxiety around food and germs.
• Client purged at least ten-times/day at age 15 and 16.
• When seen by the therapist for the first time she had not purged for two weeks because she was worried that the act of purging would contaminate her hand.
• Client eats when in the company of her best friend.

Family information and background:

• Complains that her mother is “mean” to her by constantly criticizing her. Mother complains that her daughter consistently lies about her eating and is trying to get attention. Her father described himself as a “buffer between the two.” He brings the client to all appointments and they spend a good deal of time together.
• The client refused to live with her family when she returned home from college. She currently lives with her best friend and her best friend’s mother. She reports that her biological mother hates her best friend’s mother with whom she is living.
• Her best friend is moving and the client plans to live with her friend’s mother.
• Her parents are embattled, having separated numerous times.

Clinician’s formulation:

The clinician feels that family dynamics must be contributing to and maintaining the problem but does not know how or where to intervene.

What has been tried clinically?

In the first session, the client was accompanied by her father who had no intention of coming into the session. The therapist persuaded the father to come in for 20 minutes, before the father left he said he had four goals for his daughter:

1. she would go back to school
2. she would get a job
3. she would start writing again
4. she would start talking to her mother

A couple of days after the initial session, the client brought her best friend and father along with her. The therapist told the father about the severity of the condition and emphasized the need for treatment. Shortly after the first session she was hospitalised due to dangerously low potassium levels from purging episodes.

Specific concerns:

The therapist queries whether FBT (the Maudsley model) would be appropriate or not seeing as the girl is 21.

How this consultation can help:

The therapist would like some ideas for proceeding with this case

Dr. Fishman’s advice to the therapist:

The essential question is what is your theory of change? IST holds that the contemporary context maintains and/or exacerbates the symptomology. In this case, it appears that the stress in this young woman’s life is being caused by the dynamics between her parents.

The crucial issue is that she is caught between her two parents. There is immense triangulation and this is the most pressing issue to be addressed. You will need to go slowly with this, when you push too hard there is always a danger of one of the parents dropping out of therapy. However, you could likely generate intensity to activate the parents to cooperate given the girl’s serious symptomatology.

I would suggest work with the parents right away, seeing as you have only met with the father, I would arrange a meeting with the mother as soon as possible. A meeting with Mother and Father together would be ideal. However, I imagine there may be too much friction in the room (the mother is probably furious because the father is so aligned with their daughter), and it may be easier initially to develop a rapport with mother alone.

The most important thing is to get the parents working together; they don’t have to like each other they just have to work together. Gently sit down with the parents and tell them what needs to happen, they need to support each other and co-parent.

As for FBT, in my experience, any skilled family therapist can effectively treat Anorexia Nervosa with the support of a primary care medical practitioner. I refer the therapist to my book Enduring Changes in Eating Disorders.

From an individual perspective conflict avoidance is a central dynamic; to the extent the bulimic avoids conflict, the more she purges. This family does not appear to have all of the facets of the psychosomatic family, described by Minuchin, Rossman and Baker, because of the severe conflict between the mother and daughter. It does appear to have other facets such as triangulation. I refer you to a paper I wrote with Salvador Minuchin, The Psychosomatic Family in Child Psychiatry.

I would utilize the IST clinical scorecard (ISTCS). I would have her doctor track potassium levels very closely as well as her purging. On my Eating Disorders website, in the “tools” section, there is a tool that helps clients track the association between conflict avoidance and the emergence of the symptom: Bulimia nervosa compulsive over-eating worksheet.

I would also use the Triangulation Scale to track the triangulation between the parents.

Example of the IST clinical scorecard applied to this case:

Objectives/goals:

To ensure the girl is generally well-functioning in the essential domains of her life. In regards to symptoms; no purging, no medical symptoms, esp. normal blood pressure (BP).

Plans:

Close monitoring by medical doctor and hospital if necessary, Family therapy. Parental cooperation and oversight.

Targets:

Decrease of purging 30% in 3 weeks, potassium back to normal range in 3 weeks. Score on instrument for conflict avoidance and symptoms decrease by 10% in 2 weeks. All these markers achieved in two months.

Measures:

Purging/week, potassium, Triangulation Scale. Father’s goals are also viable (i.e., go back to school, get a job, start writing again and start talking to her mother) as markers to determine the effectiveness of therapy, CAFAS, Conflict avoidance and symptoms scale.

Homeostatic Maintainer:

It is hard to determine by the description provided by the therapist what or who the HM is. The HM is best determined by who activates to maintain the system in status quo when it is perturbed. At this point we know nothing about mother.

Note: one of the most telling things about the structure of the system is when the father described himself as “a buffer”, it suggests that there’s an equal relationship between the mother and the girl. In the structural model, father and mother should be aligned and there should be a generational hierarchy. Instead, it seems father has not taken sides, if you will.

As for the compulsiveness, is see it as repressed anger generated by her social context. As the pioneer family therapist used to say, “the body says what the mouth won’t. To the extent that her system transforms, she will have more of voice and feel safer to advocate for her desires. And, most importantly, she won’t be so angry all the time.