AB: Here’s a glimpse into a  family therapy story  with an anorectic teenager. I learned a lot from this case; I hope it has resonance for our readers:

I first saw seventeen-year old Melinda and her family at the urging of their family doctor. Melinda had been practicing the dubious art of anorexia for several years, and at the time of our first meeting she was consuming a carefully-controlled 400 calories a day. She had just begun working with a nutritionist. The parents finally agreed to call me for a consultation.

UnknownMy first couple of meetings with this well-groomed , picture-perfect family was both intriguing and infuriating. The mom, Cassandra, a Swiss-born beauty, radiated an anxious need for approval and harmony. Each time she spoke she looked at the family for signs of confirmation. She clearly didn’t want anything to disturb this image of lovely family harmony.  And her husband John cooperated by agreeing  with everything his wife said. “Agreement” was his middle name.

John, the dad, was a German-born guy  who worked as a journalist for an international finance magazine. He looked like an aging punk rocker. This was his second marriage; he described his previous wife as “unstable”. He had a twenty-two year old son, Frederick, from this marriage who continued to be “a hand-full”; he had been hospitalized for drug addiction, and was struggling to stay “clean.” John appeared to carry a lot of  guilt  toward his son whose behavior created a fair amount of disruption in John’s second family.

The Therapy:  Here’a snapshot of what happened with this family therapy.  At times I felt like Alice in Wonderland, trapped in an absurd world where normal responses are regarded as suspect. The family culture, unconsciously promoted by the parents, looked to me something like this:

l. No one will disagree

2. No one will raise their voice

3. We will be happy

4. We will have fun

5. We will think alike

6. We will love each other all the time

This pattern first appeared when I noticed that every time Melinda spoke, the parents and her brother disqualified her. Melinda, and academic super-achiever, was enrolled in an advanced high school for bright, hard-working kids. She was hugely perceptive but  her point of view didn’t gain any traction in her  family.

Unknown-1Melinda would put forth some relatively mild comment related to her own privacy, or wanting her parents–-read, mother–-to treat her differently. Melinda was clearly out-of- step with “how the family does things.” Any comment about a personal preference felt like an assault on “the family”. The slightest challenge to her mother was treated as betrayal. She was the family scapegoat and troublemaker. I was pretty sure that her eating disorder related in part to her inability to have an autonomous voice in this family of super-togetherness.

I spent the first few sessions sharing my observations in a way that challenged the family norms. I used my whole being to try to create a sense of differentiation in this family. I encouraged–-no, begged–-for different opinions, different voices. I chided Dad for his “Mr. Agreement” persona. I told Mother she had a band-aid for everything. I said it looked like she thought no one should ever be upset over anything.

Every comment I made which had a bit of tension in it was blocked by mother. If I challenged the family “togetherness” Mother would look around innocently, like I was an invader coming to hurt her tribe. She didn’t want to think that there were any problems in how the family was operating. Melinda was the problem. Couldn’t I see that? This pattern was (inwardly) infuriating for me. I began to feel like Melinda. Nothing could get through in this family. One voice or no voice. Then we had what I thought might be our final session.

UnknownThe parents showed up with just Melinda. They decided to leave Adam at home, stating that something had happened over the weekend with Melinda that they wanted to discuss “privately”. (I inwardly took this as a challenge to me, since I made it clear that everyone needed to be at our sessions. I decided not to take the bait.)

Mother began describing an “uproar” where they had an argument with Melinda which ended with Melinda breaking a plate on the ground and throwing some silverware for good measure. The family was calm (of course) when recounting this story and said they’d had a “good discussion” afterward.

I thought that this might be some health breaking through. Melinda’s anger turned outward, openly directed at her parents. It sounded more dramatic than dangerous. I asked about what transpired that led to the escalation. Melinda talked about how she came down to dinner and felt “quiet”, not much in the mood to engage with her folks. She said, “My mom wouldn’t leave me alone. She kept asking what’s wrong, what’s wrong, what’s wrong. I didn’t know what was wrong. I just didn’t feel like having a big smile on my face.”

Bingo. I wanted Mother to explore her daughter’s perspective, but she shut it down. Instead, Cassandra tried to re-direct her daughter to a “happier” thought and I stopped the conversation. I said, “Melinda is trying to help you to understand what she needs as a seventeen-year old. It sounds  like she needed some space.” Mother of course took this as a minor insult, and kept anxiously talking, mostly ignoring my comment. I stopped her again.

I said, “Nothing gets digested in this family. Your daughter says many, many important, useful things that would help you to know what she needs from you. But nothing gets digested. You just keep going.” I insisted on a few minutes of silence in the session. I felt that if I could amplify Melinda’s voice she might gain some real, healthy control in her relationship with her mother instead of the pseudo-control of starving herself.

images-6I could almost see the steam coming our of Mother’s ears. I said, “You know, I feel like such a Scrooge with your family. I feel like the bubble-burster, the one who came to rain on your parade. The groove-blower.” “I feel like Angry Guy.” I said this with a smile and the tension lessened.

Then Melinda launched into a gorgeous soliloquy that contained so much wisdom, and so much health. She looked at her mom and said, “It’s not that I don’t want to be part of this family. I love you. I WANT to be in the family. But if I say I want to do something myself, like wake myself up in the morning, you say, ‘Well, then you can just do your own laundry.’ You act like if I want to do something my way that I’m hurting you. And then I feel guilty.” This soft-spoken young woman continued in this vein for a few minutes, telling her folks everything they needed to know for healing to begin.

If I could have applauded I would have. But I did the next best thing, I held my hand up for silence. I didn’t want Mother to move in and disqualify her daughter’s comments. I wanted to let Melinda’s description of her experience in this family ring out in the room without distortion.

images-6Since we neared the end of the session, I thought it was a good time to end. I could see that Mom was mad at me. I was interfering with the script that she had so meticulously honed over these past years. I knew she saw herself as the family doctor and my support of her daughter’s “trouble-making” probably offended her pride, at the very least. But I greatly admired this daughter and wanted to help her stop hurting herself. I had to risk Mother’s animosity if we were going to get anywhere.

We ended the session without scheduling another one. I didn’t know if I would see them again. I heard from their family doctor that they were “shopping around” for another therapist. But then the mother called two days later. She said, “You know, I was very mad at you the other day. We interviewed some individual therapists for Melinda, and they all told us to stick with the family therapy.” She added, “This is difficult for me. It’s not at all what I expected. But I’m starting to think it’s very helpful. So we’ll stick with you through this painful journey.” I could hear the smile in her voice. I was glad to have the opportunity to support her and confirm her. Despite her exasperating ways, I liked Cassandra. I told her, “I’m impressed by how you’re responding. I know it’s difficult, but I know you’re an intelligent and thoughtful person. I’m impressed.” She needed that from me, and I was glad to give it to her.

She added, “I know Adam doesn’t want to come, but I’m going to make him attend. I don’t care if he’s mad at me. That’s what we’re supposed to do as parents, right?” Now it was my turn to smile.

P.S: At that session, Melinda and her family reported that she  was  now eating 1200 calories a day. She looked much better.

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