Case Study 5

The following case study illustrates the use of enhanced CBT in the treatment of a Korean adolescent girl with bulimia. The case study provides a question for viewers to consider and reflect on.

Case Study 5: Bulimia (Korean)

(Adapted from Smart, 2009).

Jae Eun a 16 year old girl has reluctantly sought treatment with the ED clinic, saying that she is feeling hopeless about her weight. She has been binge eating a couple of times a week for over two years and has gained over 6 kgs over this time. She is distressed that her bingeing has increased and has begun vomiting in secret. In tears, she says “I have so much going for me and my whole family is upset that I can’t control myself”, “It’s not their fault though. They just want the best for me”.

Jae Eun is a 1.5 generation Korean who migrated from Korea with her parents as a one-year old. She is doing well at school and is top of her class in maths. Jae Eun plans to go to university and to major in Maths. Her parents run a successful Sushi café chain. Jae Eun considers herself a “Koiwi” (part Korean and part New Zealander). She tells the therapist that her parents are “more Korean and really conservative”.

Jae Eun attributes her body dissatisfaction to her first ever visit to Korea at age 14, saying that the girls and young women there were consumed with fashion and slimness. She is now considering getting eye surgery popular in Korea (to make her eyes rounder). She says that she is “huge” compared to her Korean friends in New Zealand and in Korea, and even though she has excelled in nearly every other area, her parents are “concerned about her future”, which she says means that they are concerned about her finding the best possible husband. She says that she has an “athletic” build and that she enjoys sports and likes the feeling of strength in her body. However, she considers herself “bulky” and “unfeminine”. She says, “I’m a pretty girl and I’m ruining the whole package because I can’t control myself”. Jae Eun’s parents have agreed to therapy with the encouragement of their GP. Her mother tells friends that she is going for weight- loss treatment.

Some initial cultural considerations in using CBT-E in this case (Smart, 2009):

• The time-limited nature and solution-focused structure: likely to be acceptable to both the client and her parents.
• Inclusion of significant others: might be useful, but consideration must be given to issues of stigma and shame, as well as hierarchy in the family system.
• Approach to therapeutic relationship: empathic but authoritative qualities would likely be helpful, but dealing with the potential for premature termination may require cultural accommodation
• Personalised formulation of what maintains the ED: potentially less stigmatising than focusing on what caused the ED, but assessment is needed as to whether the linear rationale fits with Jae Eun’s belief system (and possibly with the family’s belief system). There is the need for awareness of how culture and gender influence the maintaining mechanisms.
• Examination of the overevaluation of shape and weight: will likely require attention to gender and culture (eg intergenerational cultural differences – See the Assessing Migrant and Refugee Children and Adolescents section) and possibly to internalised racism. Exploration is needed as to whether there is a connection between the need for eye surgery and ED
• Possible use of the expanded form of the treatment: would allow for more work with the cultural influences on perfectionism, self-esteem, and interpersonal relationships. (See Fairburn (2008; 2008a) for a full description of the treatment - http://www.credo-oxford.com/4.1.html).

Excerpts of the therapy process with the client

The therapist is a European woman in her early 40s. Following the initial assessment process, she meets with Jae Eun (who brings her older sister to this one meeting) to describe CBT-E. Jae Eun appears anxious about the strong behavioural focus of the first month. However, she understands the logic that bingeing and vomiting is not helping her to control her weight, and she agrees to “try anything”. He sister agrees to explain things to their parents.

Jae Eun and the therapist work together on a tentative formulation of maintaining mechanisms related to her bingeing and purging. Jae Eun makes the following connections: (a) “I am letting down my family by being at this weight” and “I don’t like my eyes” (overvaluation of weight and shape); (b) “Restricting makes me feel better temporarily but then I binge”; (c) “When I am criticised or don’t do well at something, I feel very guilty, which also makes me binge”; (d) Bingeing makes me want to vomit”; and (e) “Vomiting creates more guilt, and sometimes leads to more bingeing and restricting”.

• The therapist initially tries to encourgage Jae Eun to rephrase the overvaluation of weight to reflect just her feelings, but suspects that she is missing the meaning of the client’s experience due to her own individualistic value system.
• Including the family in the formulation seems to be a necessary cultural accommodation, and the therapist works to understand that Jae Eun views her weight not as her own, but as a reflection on the family.
• Although Jae Eun readily grasps the logic of the formulation, looking at it presented in a written form upsets her and she cries. She feels very hurt by her mother’s frequent criticisms of her weight and she hates the comparisons made with her “perfect” sister. Jae Eun works hard to stop crying and is very embarrassed by her outburst. The therapist reflects gently how difficult the process is, and keeps in mind that cultural values of emotional restraint and protecting the family will be influencing Jae Eun’s responses.
• CBT-E attends carefully to the client’s ambivalence, and the therapist asks Jae Eun directly how she feels about the process of therapy. Jae Eun says “it’s fine” but will not elaborate. There is no indication of therapist self-disclosure in Fairburn’s (2008) text, but a cultural accommodation may be useful. The therapist says to Jae Eun: “You’ve mentioned the pressure from your family a number of times, as well as how much you love and value them, and I want to be sensitive to that as we proceed. I’m aware that we’re from different cultures, and we might have some different ideas about families and women’s roles based on that. It seems like it might also be hard to tell someone like me if there’s anything you don’t agree with or have questions about in the treatment”. Jae Eun responds with “No, it’s okay” at the time, later she stated that she appreciated the therapist’s effort.
• Jae Eun engages actively in learning regular eating and in doing the homework assigned. They go over Jae Eun’s reactions to the homework. Two adaptations to this exercise were made. The therapist makes an effort to learn about Korean food, which was mostly what Jae Eun ate at home and around which a number of her food battles occur. In addition, Jae Eun is asked to track the cultural dilemmas and influences that occur as she tries to follow the recommendations of the therapis.  For example, Jae Eun feelsthat she cannot set limits on the amount of food her mother and relatives gave her. Although similar struggles occur for clients across cultures, the therapist realises that it is exceptionally hard for Jae Eun to challenge her parents, given traditional values of filial piety and hierarchy in the family. The therapist asks Jae Eun if she can bring her mother for a session or two, where she could provide some education about EDs and the treatment. But Jae Eun is sure that this would offend her parents and create more problems.
• As the first phase of treatment is ending, it is clear that this is not working optimally. Jae Eun has altered some of her behaviours, and is externally compliant, but her mind set remains completely fixed. Her tears continue as do her statements that she is letting down the family. Jae Eun and the therapist go back through the formulation and talk about what barriers are keeping the treatment from working. Jae Eun finally states that she is very sensitive to her mother’s criticisms but has also become increasingly fearful of disappointing anyone, and believes that letting family and friends know who she really is or what she feels would be entirely unacceptable. She also admits that she wants to go out with a European guy she knows and that in future she wants some sexual experience before she gets married, but that such activities would have to be kept secret. To a significant degree, the function of ED within her cultural context appears to be a way for her to express and manage the distress of conflicting values.
• Together, Jae Eun and the therapist decide to add the interpersonal component to the treatment, believing that it will help increase self-esteem as well. Interpersonal Psychotherapy (IPT) is targeted to “grief, interpersonal role disputes, role transitions, and interpersonal role deficits” (Fairburn et al., 2008b, p. 217). In this case, the role disputes and transitions are adapted to address Jae Eun’s developmental stage, her emerging bicultural identity, and the interpersonal difficulties caused in part by the acculturation differences between herself and her parents.
• This represents a significant shift in the treatment, as the IPT module is a different therapy from CBT and is far less solution-focused. Sessions were lengthened, and one half was devoted to IPT and the other to CBT. The IPT module helps Jae Eun identify how certain relational patterns occur and contributes to her cycles of anger, guilt and shame. It permits a deeper discussion of how her bicultural identity puts her at odds with her parents at times and also leads to confusion about her role as a young woman. Jae Eun begins to reframe some of her mother’s critical comments: not accepting them, but understanding more about their intent and learning ways to defuse her reactions and conflicts. Although she is committed to honouring her family, she begins to question the utility of making physical appearance the only way that she can do that.
• Simultaneously, the CBT portion deepens and Jae Eun is able to explore how her thoughts about her weight and eyes are impacted by sexist and racist notions in Western society. In other words, her mind set begins to shift and the behavioural changes she has been adopting start to make more sense to her and take greater hold.