by Lucia Fernandez Alvarez, M.S.ED. and Andrea S. Corn, Psy.D.
We received a desperate phone call from Mrs. Ortiz several days ago saying, "I don't know what to do! I'm getting scared! Maria is not eating and is losing weight. She's trying to control my life again, I don't know why! She was doing so well! Please, what do I do?! We need family therapy again, I know we do. Can you help us, please?!"
In her voice there was anxiety, tur moil, and guilt-ridden desperation. In fact, during the entire time Maria was hospitalized, mother spoke of feelings of shame and hopelessness. These emo tions were connected to her own per sonal deficits with respect to being Maria's mother. Mrs. Ortiz's resistance in therapy was quite pronounced. Ther apy was terminated prematurely, even though Maria had stabilized at a low, although acceptable, weight and had had two consecutive menstrual cycles. However, many issues remained unre solved. Maria's eating disorder sym bolized her way to passively defy her mother and rebel against being the com pliant, "perfect" daughter. We were not surprised to find the same issues still at hand months later. These matters re volved around Maria feeling emotional ly starved for a nurturing mother, her
onflicts over not being able to "stomach" her mother's intrusiveness while being very dependent upon her, and withholding all angry feelings out ;)f fear of losing mother or worse, be mg rejected by her. The onset of ano ::cxia nervosa became a compensatory ~echanism for Maria to pursue auto - my in a maladaptive way. Food re ::.:Sal was the way this patient obtained ::. sense of separateness, mastery and
trol over bodily functioning and ~:-functional interpersonal regulation.
S{ anoretic patients, like Maria, have :- I difficulty in acknowledging their -::s-s about growing up, their lack of ':-.:>Onal control, and repressed hostili - ~r was difficult for Maria to perceive
• her behaviors and attitudes toward -=::, body image and self regulation :; distorted.
Lucia Fernandez Alvarez, M.S.ED.
Again it took a crisis for mother to face her ambivalent desires about re turning to family therapy. Previously, it was too painful for mother to ac knowledge her own maternal inade quacies. Instead she chose to focus on changing her daughter's precarious low weight and compromised physical health. Mrs. Ortiz saw this as the way to correct the eating disorder. Only by understanding and confronting their emotional problems could there be any hope for lasting improvement.
This demonstrates why family therapy has to be an essential and integral part of the multidisciplinary approach in treating anorexia nervosa patients. One of the first steps in understanding this perplexing disorder is recognizing that it is afamily problem. The environment in which these patients have grown up has played a significant role in the crea tion and maintenance of this profoundly disturbing and sometimes fatal disorder. Despite the fact that the identified pa tient is usually an adolescent offspring, the symptoms did not originate here. In actuality, it is the transgeneratio~ s fluences that become physi ':, "ffiG tionally, and ultimatel,- . sy:~o_o~·cal· ly personified. These cs:- =--:;. - of in terpersonal relail2= :.=z:: ~ave been handed do.... g genera-
tions. This linkage is rooted within the parental figures, and it is the patient who internalizes, assimilates, and acts out idiosyncratic ways of interacting and responding. These feelings, attitudes, and self-attributions are derived from the patient's most significant and earliest relationship, which usually cor responds to the mother. This theoretical model is based on an object relations perspective which stresses the establish ment of the mother-infant relationship, and the quality and ongoing nature of this attachment as central in the de velopment of all subsequent relation ships. Consequently, difficulties arise from unresolved conflicts contained within this formative interpersonal relationship.
Even though every family i a unique entity, several general patterns "ill be found amongst the families 0 anorec tic patients: the fam.ily " ually highly enmeshed, the patie :' usually passive and 0 -erly co lia:1[ [he mother is usuall.- .~~ 0.- and ontrolling, boun .~--:?S cse in -aded, and sexuality is ~ . and Slumed. The family's tenden-
: 0 sabotage treatment is frequent and e,-idem in all disciplines (medically, psychiatrically and psychologically).
| MIAMI MEDlCINE/SEPT£\.fBER 1994 |
35 |
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| 36 |
MIAMI MEDICINE/SEPTEMBER 1994 |
(continued from page 35)
Generally, the family tends to deny or minimize the seriousness of the psycho pathology. Collectively, the family car ries a tremendous sense of guilt and feel ings of inadequacy related to the devel opment of this illness.
In treating the family, it is crucial not to be judgmental, as the sense of guilt that already exists continues to feed into the feelings of inadequacy that underlie this disorder. In our sessions with Maria and her family, our job as therapist and co-therapist was to be empathic, help contain, and then process intolerable af fects of rage, abandonment and inter personal neediness. Both mother and daughter had experienced their mother's emotional unavailability and perceived rejection as a threat to their own sur vival. In family therapy, Maria was able to hear mother's disavowed pain sur face. Gradually, Maria became aware that while they each held similar feelings of anger, rage and helplessness, they were separate individuals. This enabled us to bring forth their central underly ing dysfunctional motif which was based on unconscious fears regarding separa-
tion and loss.
Understanding the family and its dynamics, therefore, is the key to understanding how these symptoms developed and the source of the dilem ma. Anorexia is a family problem, a family pain, held in a fragile, emaciated, skeletal body . . . 0
(The patient mentioned in this article is a 17-year-oldfemale that was treated at Miami Children's Hospital for anorexia nervosa with severe malnutrition. The names have been changed to protect the patient and her family.)
Lucia Fernandez Alvarez, M.S.ED. is a family therapist at Miami Children's Hospital and in private practice in S. Miami.
Andrea S. Corn recently received her Psy.D. from Nova-Southeastern Uni versity and is completing her doctoral internship at Miami Children's Hospital.
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& Florida Chapter, American CcIIege of Surgeons
1000 Riverside Avenue • Jacksonville, Florida 32204 1-800-741-3742· 904-354-5910
PUT A CAP ON YOUR VACATION TIME.
Now there are 20 New Reasons to make your next vacation a Watt Disney World vacation. Extraordinary celebrations, incredible events, gigantic surprises, and exciting attractions awaIT you at the Watt Disney World Resort in Florida.
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YEARS -6ll-I1Uorldo
e DISNEY
• OVER 30 YEARS OF EXPERIENCE IN ALL ASPECTS OF HEALTH CARE MANAGEMENT, ACCOUNTING & TAX SERVICE.
• CONTACT HAROLD KWART, RONI LASKIN OR GLEN BUTRICK FOR A CONSULTATION WITHOUT OBLIGATION.
PROFESSIONAL CONSULTANTS & ASSOCIATES
18305 Biscayne Boulevard, Suite 214 North Miami Beach, Florida 33160 Telephone 305/931-4546
| 36 |
MIAMI MEDICINE/SEPTEMBER 1994 |
(continued from page 35)
Generally, the family tends to deny or minimize the seriousness of the psycho pathology. Collectively, the family car ries a tremendous sense of guilt and feel ings of inadequacy related to the devel opment of this illness.
In treating the family, it is crucial not to be judgmental, as the sense of guilt that already exists continues to feed into the feelings of inadequacy that underlie this disorder. In our sessions with Maria and her family, our job as therapist and co-therapist was to be empathic, help contain, and then process intolerable af fects of rage, abandonment and inter personal neediness. Both mother and daughter had experienced their mother's emotional unavailability and perceived rejection as a threat to their own sur vival. In family therapy, Maria was able to hear mother's disavowed pain sur face. Gradually, Maria became aware that while they each held similar feelings of anger, rage and helplessness, they were separate individuals. This enabled us to bring forth their central underly ing dysfunctional motif which was based on unconscious fears regarding separa-
tion and loss.
Understanding the family and its dynamics, therefore, is the key to understanding how these symptoms developed and the source of the dilem ma. Anorexia is a family problem, a family pain, held in a fragile, emaciated, skeletal body . . . 0
(The patient mentioned in this article is a 17-year-oldfemale that was treated at Miami Children's Hospital for anorexia nervosa with severe malnutrition. The names have been changed to protect the patient and her family.)
Lucia Fernandez Alvarez, M.S.ED. is a family therapist at Miami Children's Hospital and in private practice in S. Miami.
Andrea S. Corn recently received her Psy.D. from Nova-Southeastern Uni versity and is completing her doctoral internship at Miami Children's Hospital.
. . . with FPIC's FCACS Discount Program, offering significant savings for surgeons In Broward, Dade, and Palm Beach Counties!
call today and find out how you can qualify!
FP/c is endorsed by the Florida Medical Association
& Florida Chapter, American College of Surgeons
1000 Riverside A venue • Jacksonville, Florida 32204 1-800-741-3742· 904-354-5910
