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Psychosomatic Families Psychosomatic Families Psychosomatic Families Anorexia Nervosa in Context Salvador Minuchin Bernice L. Rosman Lester Baker With a Contribution by Ronald Liebman HARVARD UNIVERSITY PRESS Cambridge, Massachusetts, and London, England Copyright © 1978 by the President and Fellows of Harvard College All rights reserved Printed in the United States of America This book has been digitally reprinted. The content remains identical to that ofprevious printings. Library of Congress Cataloging in Publication Data Minchin, Salvador. Psychosomatic families. Includes index. 1. Anorexia nervosa. 2. Medicine, Psychosomatic. 3. Family psychotherapy. I. Rosman, Bernice L., joint author. II. Baker, Lester, joint author. III. Title. RC552.A5M56 616.8'5 78-1742 ISBN 0-674-72220-5 To the first diabetic children Karen, Patricia, and Deborah who forced us to look at the critical role of the family in psychosomatic disease Acknowledgments This book is the end result of ten years of research on families with psychosomatic children, supported by Grants NIMH 21336 and NIH AM 13518. The research on the children who were hospitalized in the Clinical Research Center of the Children's Hos­ pital of Philadelphia as part of this study was supported by Grant NIH RR240. The authors of the book represent an interdisciplinary team: psychiatrist, pediatrician, and psychologist. Yet the contributions of these individuals represented far more than the sum of their areas of expertise. In the process of working together, we developed a system of differentiated but interdependent parts. The psychiatric input was enhanced by the contribution of Ronald Liebman, M.D., who wrote Chapter 10 and was the therapist for a number of the cases followed in the outcome study. Thomas Todd, Ph.D., and Leroy Milman, M.D., who completed the team, contributed greatly to the development of ideas contained in the bool(. Many other colleagues, students, and teachers at the Philadelphia Child Guidance Clinic and the Clinical Research Center participated in the treatment of the families and in the research meetings creat­ ing the atmosphere of curiosity, excitement, and exploration that sustained us through the difficulties of the project. They helped us to crystallize our ideas and encouraged us in their presentation. Among them, we owe special thanks to Lynn Hoffman, who sug­ gested the format of analysis that was used in the clinical chap­ ters; Gottlieb Guntern, who read the manuscript and gave useful suggestions; Patricia Minuchin, Ph.D., who helped with the orga­ nization of the book and in other aspects of the writing; Fran Hitch­ cock, whose collaboration in the writing and editing was invalu- viii / Acknowledgments able; Sherry Bell and Joyce Kobayashi, who carried out the follow­ up study; and Marge Arnold, who patiently typed many drafts and redrafts of the book. We also want to thank Virginia LaPlante from Harvard University Press for her contribution to the finished work. Another group of people who collaborated in our book, though anonymous, are the most significant contributors of all. They are the families we studied, who endured our uncertainty and groping and helped us to grow. To them go our warmest thanks. The transcripts of therapeutic interviews appearing in this book have been edited to protect the privacy of the families involved. The family interviews have also been made into training videotapes, under the titles: IIPeople Take My Voice," with commentary by Lynn Hoffman (Chapter 8); IIRescue Mission," edited by Gottlieb Guntern, M.D., with the assistance of Giovanna Todini, M.D., and David Heard, Ph.D. (Chapter 9); liThe Priestman Family" (Chapter 10); and liThe Menotti Family" (Chapter 11). Information concern­ ing these videotapes is available from the Philadelphia Child Guid­ ance Clinic, Two Children's Center, 34th and Civic Center Boule­ vard, Philadelphia, Pennsylvania 19104. Contents 1 Perspectives on Anorexia Nervosa 1 2 The Psychosomatic Family 23 3 The Anorectic Family 51 4 Blueprints for Therapy 74 5 Strategies for Change 92 6 The Opening Moves 108 7 The Outcome 126 8 The Kaplan Family 139 9 The Gilbert Family 204 10 The Priestman Family 241 11 The Menotti Family 281 12 Psychotherapy for a Small Planet 323 Appendix A. The Family Task 335 Appendix B. Research in Endocrine Adaptation 338 Notes 340 Index 347 Figures 1. Linear model of psychosomatic disease 15 2. Open systems model of psychosomatic disease 21 3. Changes in FFA levels of anorectic children during family intervievv 47 4. Medians of parent vvith higher FFA response and index patient 48 5. Individual vveight changes of eight anorectic patients before and after lunch session 123 6. Composite vveight changes of eight anorectic patients before and after lunch session 124 Tables 1. Behavior protocol during hospitalization of anorectic patients 115 2. Weight changes of eight anorectic patients four days before and after lunch session 125 3. Characteristics of fifty-three anorectic patients prior to participation in family therapy research program 128 4. Treatment and follovv-up of fifty-three anorectic patients 129 5. Medical and psychosocial assessment of fifty anorectic patients following family therapy 134 Psychosomatic Families Perspectives on Anorexia Nervosa 1-------- At the age of fourteen, Deborah Kaplan developed the syndrome known as anorexia nervosa, or self-starvation. Typically, the illness seems to have begun when she decided to go on a diet in order to pursue a career as a model. At first she followed a normal reducing diet. But over a period of eighteen months she cut out more and more foods, until she was eating only apples, cottage cheese, and water. Her weight dropped from 110 pounds to 78 pounds, and amenorrhea developed. At the same time, Deborah's activity increased. Sometimes she would wake up at four or five in the morning and go out to walk for miles until it was time to leave for school. If confined to the house, she ran endlessly up and down the stairs. She continued to be a good student, as she always had been, but she withdrew almost entirely from the social activi­ ties of school and synagogue. Deborah's parents described her as a good girl. They were proud of her grades and her behavior. They could not explain her refusal to eat. Finally, on her pediatrician's recommendation, Deborah was hos­ pitalized in a children's facility that was researching family influ­ ences on psychosomatic syndromes in children. Rigorous medical workups ruled out the possibility of an organic cause for her refusal to eat, so Deborah and her family were referred to the psychiatric component of the team. The presenting problem was anorexia nervosa. Anorexia nervosa is a psychosomatic syndrome characterized by both physical and psychological symptoms. It is potentially fatal, with reported mortality rates of 10-15 percent. The disease usually appears in middle class females, the percentage of male anorectics being very low. It generally starts during adolescence, though cases can also begin in preadolescence and in adulthood.1 2 / Psychosomatic Families There is some debate in the medical field concerning the exact components of the syndrome. In this study the disease is defined by both physical and psychological criteria. The physical symptoms include a loss of over 25 percent of the body weight as well as one or more of the following conditions: amenorrhea, hyperactivity, and hypothermia. The psychological symptoms include a pursuit of thinness, fear of gaining weight, denial of hunger, distorted body image, sense of ineffectiveness, and struggle for control. As is usual in our practic.e, the first session held at the psychiatric clinic with the Kaplan family was planned to incillde lunch.2 Present at the interview were Deborah, her parents, and her seventeen­ year-old brother, Simon. When Deborah was earlier negotiating with the dietitian at the hospital, she had ordered a hot dog, peas, milk, and cottage cheese, to be sent over on a tray for lunch. The family and the therapist ordered sandwiches during the session. But when Deborah's tray arrived, she refused to eat. Consequently, the therapist instructed the parents to take over the task of getting their daughter to eat while he was out of the room. MINUCHIN: I will be watching through the one-way mirror. I will come back shortly. I want you to negotiate with Debbie. Otherwise she will die. She is starving herself to death. I don't want that to happen. And she is your daughter. (He exits.) MOTHER: Deborah, do you want to finish this half of my sand­ wich? It is very good. DEBORAH: Dad, I told you last night that I didn't like it. But I tried it. FATHER: Are you talking to me? I told you that you are going to have to eat everything. When you get up to a certain weight, you can pick your own shots, but right now, we are negotiating for your survival, like Dr. Minuchin said. Your life. It is important that you eat. DEBORAH: The dietitian was up here, and she asked me what I wanted to eat. MOTHER: You are old enough to understand. Dr. Minuchin was just in here. And before you came to the hospital, I told you that you were going to die. Do you know what that means, Deborah? You are going to die! You have a beautiful life ahead of you-you are only fifteen! Deborah, this contains protein- FATHER: Deborah, how many doctors have told you that you are Perspectives on Anorexia Nervosa / 3 not a dietitian? Now wipe out of your mind what those things con­ tain, and just eat them. MOTHER: Let her finish eating. I think she is going to try to eat. DEBORAH: I was talking to a real dietitian here. She told me to order what I wanted.
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