Case Study 6

The following case study illustrates the role of socio-cultural factors in the course of anorexia in a Chinese adolescent girl. The case study provides a question for viewers to consider and reflect on.

Case Study 6: Anorexia nervosa (Chinese)

(Adapted from Rhodes, 2003)

Sally Wong is a thirteen year old girl admitted to hospital for the first time, with a weight of 32.9kg and a body mass index of 13.82. She was medically compromised with bradycardia (slow heart rate), hypothermia, and protein calorie malnutrition, including muscle wasting and poor peripheral blood flow. She was admitted for a total of eight weeks and commenced on overnight nasogastric feeds and a supervised menu plan during the day. She remained on bed rest for the first three weeks, and after five weeks graduated to supervised menu plan only. She attended the hospital school during her admission, as well as physiotherapy, and recreational group programmes. Family and individual meetings in the hospital were limited to diagnostic screening, psychoeducation, and general support. These in-patient meetings were not conducted by the therapist responsible for her outpatient family therapy. Sally’s discharge weight was 35.8kg. Sally’s family consists of her father, Winston, who works as a caretaker, her mother Leanne, who works part-time as a secretary, and her brother Michael, who is eight years old. The family is of mainland Chinese origin and immigrated to New Zealand thirteen years ago.

The therapist’s first contact with the family was by telephone. The therapist introduced himself and explained his role as helping them with Sally’s recovery once she was discharged from hospital. The family was then sent a short letter that reiterated points from the telephone conversation.

Dear Mr and Mrs Wong,

 

It was good to speak with you yesterday on the telephone to make an appointment for our first family meeting to help you with Sally who is suffering from Anorexia Nervosa. I am particularly concerned about how she will progress once she is discharged from hospital and believe that you will be incredibly important in helping her to return to health. As we discussed, Anorexia Nervosa has the highest mortality rate of any psychiatric illness. We will all need to work extremely hard to make sure that she can recover.

 

It is very important that every member of your family come to our meetings at the hospital. Each of you will have been affected by the anorexia and each of you will also have something important to offer, in standing up to the grip it has had on the family. It may be difficult at times for all of you to attend, but it is vital given how extremely vulnerable your daughter is at the moment.

 

I look forward to meeting you all at 1:00 in the Medical Centre. Could you please come fifteen minutes early so that our nurse can weigh Sally before we meet.

 

Yours sincerely,

The First Family Meeting

In the first family meeting, the parents described the effect that the anorexia had had on them since its onset six months ago. Both described how distressed they had been by her admission to hospital, but also expressed some relief due to feeling that they had not known how to help her at home. Winston was eager to point out that he felt Leanne was responsible for the severity of Sally’s illness because she had been less prepared to accept the illness than he. Further circular questions revealed that Winston’s criticism of his wife was also related to his own guilt regarding the illness.

Both parents were found to be united in blaming themselves and this was framed by the therapist as one of the anorexia’s manipulative tricks. Further questions were used to extend this process of externalisation to Sally. The anorexia was seen as more in control of Sally than vice versa. The anorexia was described as having been successful in deceiving her into seeing herself as fat, and also at getting her to drink water before her initial weighings at her General Practitioner’s surgery. No exercising was reported. Michael was observed to be actively involved in reporting on Sally’s behaviour, and Sally said that he often did this at home. Sally angrily stated that it had had a negative effect on their relationship. The therapist then summarised the session so far, taking great pains to empathise with the family’s suffering over the past six months.

The family was then asked what effect the anorexia would have on Sally if it continued to take charge over the next twelve months. Winston and Leanne described how her growth might be stunted and how her reproductive system might be damaged. The therapist described other possible medical complications as well as the risk that it could kill her. The family was visibly shocked by this, but the parents still stated that they would do whatever was possible to help her. The session was then summarised and the family was charged with the responsibility of standing up to the illness. The therapist expressed his firm belief that they were the best resource for this purpose. Arrangements were then made for the next session, the family meal.

The Family Meal

This session was held at 12.30 p.m. to coincide with lunchtime. Leanne brought ham sandwiches, fruit, and orange juice from home, and Winston brought a large serve of noodles and vegetables that he had purchased near his workplace. The parents were asked to attempt to get Sally to eat one more mouthful than she wanted to. Sally was also asked to resist their attempts so that they could gain some practice in taking charge of the illness.

Michael was asked not to join his parents but to watch out for any signs of distress in Sally. During the early stages of the meal, the therapist asked the family questions about eating habits at home. Sally and Michael typically ate breakfast on their own, while Leanne made school lunches and Winston got ready for work. Winston was rarely present for dinner, but the remaining family members sat together. Sally was reported to eat the same food as the rest of the family, but in smaller quantities. Further questions, however, revealed that Sally often ate chicken when the others ate red meat.

Leanne had also taken to buying low fat milk and yoghurt instead of full fat dairy products. The parents were asked to consult their instincts about the kind and quantity of food that Sally would need to eat to gain a healthy weight. They both felt that she should be eating high fat dairy products and red meat, and should also be eating the same size servings as the rest of the family. At this point in the interview Sally had finished her sandwich and juice but stated that she did not want any fruit. Winston then proceeded to lean across Michael’s seat to ask Sally to try some noodles. The therapist asked Michael to move so that Winston and Leanne were sitting on either side of Sally. Winston was persistent in his requests, which was praised by the therapist. Sally became angry after the fourth request, telling him curtly to change seats again. The therapist then asked Michael to guess what effect his father’s attempts were having on Sally. He said she was angry because she would feel her father was hassling her. He also felt that she did not like being hassled in front of the therapist, whom she did not know very well. Sally agreed with these guesses and her anger seemed to settle. Winston and Leanne were then asked to continue standing up to the illness.

This process continued for twenty more minutes. On one occasion Leanne started to negotiate with Sally about the caloric content of the noodles. The therapist then asked Leanne if she had done this before and how effective it had been. She was encouraged to continue the monotonous requests with her husband. At 1.25 p.m. Sally asked the therapist if she had to eat a lot or only one taste. The therapist referred this question to the parents who indicated that she only had to have one mouthful. Sally then proceeded to eat this just in time for the end of the session. The family were congratulated on their success, but agreed that this process might be a lot harder at home. They agreed to eat their breakfast together, and Winston said that he would arrange with his work to be home for dinner two week nights per week.

Continued Focus on the Refeeding Process

The remainder of Phase I took nine weekly sessions. In this time Sally’s weight rose to 40.5kg, with no weight gain in the first two weeks and a decrease of 500g on week five. In the first two weeks, the parents had been successful in introducing high fat dairy products, but Sally had compensated by 30-minute daily periods of exercising in her room. The parents then agreed to stand up to this behaviour and developed a joint strategy of checking on her every five minutes when she was in her room. The therapist was careful to reinforce their success with dairy products, and their team approach to exercising. Michael had some difficulty forming an alliance with Sally in this first two-week period and was tempted on numerous occasions to join the parenting team in their refeeding task. Sally said this made her feel like everyone in the family was against her.

Winston and Leanne decided to help Michael by reminding him when he attempted to join them. From this point on, Winston and Leanne progressed well with the refeeding task. Michael also improved in his attempts to form an alliance with Sally. They had little success with getting Sally to eat red meat, but increased her intake of chicken and pork instead. They were gradually able to increase the amount of food she ate at each meal.

Their main strategy was to insist monotonously, but they also developed more creative approaches. One strategy was to remind Sally how much she had disliked her stay in hospital. Another was to name anorexia ‘Annie’ and remind her jokingly when it was bossing her around. One two occasions Leanne became angry with Sally during refeeding when Winston was not home at dinnertime. Winston decided to call Leanne on the nights when he could not be home, to support her in the refeeding process. The family expressed some disappointment at week five when Sally lost 500g. The father requested that the therapist focus on telling his wife that she was responsible and stated that Leanne and Sally were both as stubborn as each other. He wondered if family relationships could be a focus of the therapy rather than simply concentrating on food. The therapist was very clear in pointing out the dangers of concentrating on issues that were not directly related to eating, given that Sally was still at serious medical risk. Further exploration of the events of this week revealed that Winston had worked very long hours due to the absence of his manager and that he had been quite critical of his wife upon his return home. This was again reframed as a product of his own concern for Sally, and as an attempt by the illness to split them up as a parenting team. The therapist revisited the collapsing time strategy from the first session, asking the parents about what might happen to Sally if the anorexia continued to be successful in this way. Careful plans were put in place to take back this ground from the illness. The father agreed to come home for dinner for the next week and both parents would follow strategies that had already worked in the past five weeks.

Phase II: Negotiating for a New Relationship

At week ten, the therapist and the parents decided to move to Phase II of treatment. The parents felt that Sally was well on her way to recovery, and expressed some relief that they had been able to take charge of the illness. They both felt comfortable with gradually handing some responsibility back to Sally. A two-week experiment was set up for Sally to eat breakfast for two days per week without her mother or father present. Her parents also allowed her to go on a day trip with a group of girl friends and planned carefully which foods she would buy and eat. Within two weeks Sally had gained another 1kg and reported menstrual spotting. The parents also reported that they no longer needed to remind her to eat. The family was now eligible for the commencement of Phase III.

Phase III: Adolescent Issues and Termination

The main adolescent concerns raised by Sally and her family involved conflict regarding Sally’s choice of social activities. Her parents were keen for her to become involved in a Chinese church and to join the youth group with other Chinese adolescents. Sally was more interested in socialising with adolescents from school from a variety of cultural backgrounds. The therapist was initially concerned that marital tensions might also be raised, due to Winston’s tendency to blame Leanne for the anorexia, but this was not the case. The therapist assumed that some degree of harmony between the couple had been achieved indirectly by the facilitation of a stronger parenting alliance. The parents and Sally were then asked to try and solve in the session the problem of Sally’s friends. They were encouraged to see this tension as a normal part of the life cycle for families from different cultural backgrounds and to find a win/win solution. Sally agreed to attend the church with her parents but not the youth group. The parents agreed to allow her to go out on the weekend with friends from school so long as they had met them beforehand. No further questions were raised. The family was seen on two more occasions over a twomonth period. The adolescent issue regarding Sally’s friends was resolved without the need for more intensive family therapy and Sally reached a weight of 41.9kg. Treatment was closed by asking the family to review their progress over the 21 weeks of treatment. The therapist expressed his confidence that they would succeed in the future if any problems arose and each family member was given an opportunity to say goodbye.