A year ago, Mr. Zhang’s family of three came into my office, most conspicuously their adolescent daughter, who was skinny and skeletal, with deep sunken eyes and a pale complexion. The couple looked to be in their fifties, older than the parents of children of the same age. They looked ordinary, plainly dressed, not like from the big city; the daughter was fashionably dressed, exquisitely groomed, well mannered, and looked very cultivated, even though so malnourished, but still could not conceal the original beauty. At first glance, I would have been surprised that such ordinary parents could raise such an exquisite daughter.
Once seated, I opened by asking them, “Who can tell me first why you are here to see me today?”
The mother first began to tell about her daughter’s condition, “My daughter Annie is such an unfortunate girl, only 16 years old, the age of flowering, but she has this ‘strange disease’ that makes her as thin as a bone …… “The mother of Annie is a middle-aged intellectual woman, teaching mathematics in a local key middle school, she expressed her daughter’s condition very organized, and always smiling, although she said she was “overwhelmed by her daughter’s illness”, but also not like other mothers will be easily moved, and even to tears, at a glance to She is a rational woman with great restraint and patience.
I learned from my mother that although Annie was only 16 years old, she had been suffering from a strange disease for three years, and she was unable to go to school because of this strange disease.
I asked Annie, “Can you tell me what kind of ‘weird disease’ your mother says you have?” Annie seemed cooperative and did not resist me on the spot like many teenagers I had met. She smiled and told me, “My strange disease is that I am afraid of gaining weight, usually I either don’t eat or I can’t control overeating and I have to throw up after overeating. But staying at home, I felt more empty and had nothing to do, I ate from morning to night and threw up every day. I was puzzled by such a great impact on her life, and she should be in deep pain, but it was as if she was talking about someone else, so I couldn’t feel her pain, and I wondered, “Where did her pain go? Why can’t I see it?”
Although I understood Annie’s strange illness, I was still curious and asked the couple, “How could your daughter, who is so well-bred, beautiful, intelligent, and perhaps even more beautiful if she were fatter, have made herself so thin and bony and would continue to be so for three years without improvement?”
Her mother immediately answered and said proudly, “Our Annie was indeed born with everyone praising her beauty and intelligence, and she was loved by everyone, she was the apple of our eye and our pride. Her father ran a foreign trade enterprise, and our plan was to train her well and send her abroad to study after high school, and then come back to work for her father. This child has always been very well behaved and obedient when she was young, always demanding of herself, never very conscious of her studies, very controlled, and always at the top of her class. To junior high school there are many boys to pursue her, sick some time ago she also talked about a boy, her father and I are firmly opposed to, afraid that she delayed the future, for this she began to ignore us, quarrel, and even run away ……”
This is a side of the father who has not yet spoken sighed, “to say that the cause of this illness, then I have to blame my bad genes, I have diabetes, my Annie unfortunately inherited early on my diabetes ……” father incomparable guilt talking about the discovery of his daughter The father talked about his daughter’s illness since he found out she had diabetes. Annie was chubby and cute three years ago, but a school physical detected an increase in blood sugar, so her parents took her to the hospital for a checkup. But the doctor also reassured them that since they found the disease early and their blood sugar was not very high, they could first treat it without medication, but only with a controlled diet and restricted food calorie intake, which should have good results. The first thing I know is that my daughter has been very strict with her “controlled eating plan”, counting calories for every meal she eats and limiting her diet, and she lost 4 pounds a month later. She wanted to lose more weight, and even consumed much less than the doctor’s recommendations. Two months later, she became thin and even stopped menstruating, and her family felt sorry for her and kept urging her to eat more. From then on, the issue of eating and not eating became the theme of the dinner table, and the home became a battlefield. However, in this war, Annie was absolutely victorious, and her parents were helpless to do anything about her, watching her continue to lose weight. Six months later, Annie developed overeating and vomiting, and they still couldn’t help her stop this behavior that both hurt her body and affected her life until she was now off school, so she had to come to the doctor for help.
After more than half an hour of building a counseling relationship with Mr. Zhang, I basically understood Annie’s condition and the reason for her illness. It can be said that Annie has developed an eating disorder due to her diabetes and the need to control her diet. Her “eating disorder (anorexia nervosa)” was manifested as follows
1. eating behavior problems: excessive control of eating, alternating between fasting and overeating, vomiting.
2. Fear of gaining weight.
3, wasting: weight below 85% of the standard weight corresponding to height, with a body mass index of only 14.5, well below the lower limit of 17.5 for healthy individuals.
4. the presence of amenorrhea for more than 3 months.
However, we found that diabetic patients suffering from eating disorders are rare, and in fact there is no necessary link between diabetes and eating disorders. So what kind of people are likely to have problems with eating disorders in a controlled diet? From Annie, we found that she had some of the following characteristics.
1. high demands on herself, excessive pursuit of perfection, not only academic excellence, but also wanting to be even more beautiful when her appearance is beautiful.
2, excessive need to gain a sense of achievement and satisfaction.
3. being obedient since childhood, when she reaches adolescence, when her self-development starts to have her own opinions (e.g., falling in love), she is firmly opposed by her parents and starts to become capricious, using actions to “speak” and confront her parents (e.g., ignoring them, running away), instead of communicating and negotiating.
4. The problem of eating behavior worsens when there is a void.
In the following interviews with the family, I found that Mr. Zhang’s family also had the following characteristics.
1, parents overprotective of their daughter since childhood: excessive love made Annie feel controlled, so she began to act against control during her rebellious adolescence. Excessive control over eating and not eating was also one of the ways she unconsciously used to fight against parental control, and it was also the strongest kind of resistance.
2. Entangled relationships among family members: family members’ boundaries are blurred, they are over-involved and over-reactive with each other, and Annie’s personal autonomy is severely limited by the family system.
3. conflict avoidance: the parents denied the existence of any conflict in the family except for the daughter’s illness, and the family maintained the image of a “good family” in front of outsiders, while the daughter’s perception was that the parents were not as “affectionate” as they said they were. Since Annie’s eating behavior problems, the parents’ full attention was given to their daughter, and their relationship seemed to improve, as if Annie’s illness also served to alleviate the parents’ conflict.
4. Family rigidity: Annie clearly expressed that she did not want to change. Although the parents realized that their overprotective approach to their daughter was problematic, they still maintained their communication with Annie in an over-pampered and over-protective manner, satisfying Annie with whatever she wanted for fear that she would become upset and aggravate her overeating behavior if she was not satisfied.
From the above observations and interviews with Annie’s family, and from what we learned about Annie’s personal and family problems, I worked with the family to develop a treatment plan.
1. Annie has serious somatic problems such as malnutrition and amenorrhea, and psychological treatment also requires joint cooperation with doctors of various disciplines. The parents needed to take her to an internist regularly for follow-up of her somatic condition, correction of possible electrolyte disorders and endocrine disorders, and various other symptomatic treatments; to see a gynecologist, especially for amenorrhea up to six months, preferably for several months of artificial cycles; and to see a nutritionist regularly for nutritional guidance on eating. Gradual normalization of Annie’s weight (BMI of 17.5 or more) is the primary goal of initial treatment.
2. To treat Annie’s emotional problems, sleep problems, and overeating behavior, appropriate psychotropic medication should be administered based on a good doctor-patient relationship.
3. Conduct weekly individual therapy with Annie. Annie was helped to recognize the relationship between her personality traits, her past life history and her illness; she was helped to understand the role that her eating behavior problems have played in her life over the past three years, to understand the psychological meaning and function behind her eating behavior problems, and to further understand why she did not want to change; she was also given health education about the physical and psychological effects of the development of her eating behavior problems and the impact of maintaining the behaviors on her future future prospects. This helped her to develop and maintain a genuine motivation to heal. We also provide help, guidance, and ongoing support for Annie’s personal problems as she grows.
4. Conduct family therapy with Annie’s family once every 2 weeks. Each member of the family was helped to understand that Annie’s illness was not her personal problem, but a metaphor for the family relationship problem, and that everyone had a role in maintaining Annie’s illness.
During the next three months of treatment, I kept working closely with the family, and they gradually realized that the controlled diet after Annie’s diabetes was not the real cause of the eating disorder, it was just a trigger, and the real cause was Annie’s personal problem as well as the family’s problem. Each of them began to face their problems and slowly tried to change, with my support and encouragement, and they gradually tasted the good results of the changes.
After three months, Annie’s problems with excessive eating control, overeating, and vomiting behaviors were greatly reduced to once or twice a week, and she gradually established a healthy eating style, eliminated excessive dieting, and developed new behavioral alternatives to overeating and vomiting, such as eating with others as much as possible, eating regularly, developing hobbies she likes after meals instead of vomiting, developing friendships in her life, setting short-term goals and long-term goals, etc., to eliminate the feeling of emptiness. Annie’s weight has increased by 10 pounds in three months, and although her BMI has increased from 14.5 to 16.6, it has not yet reached 17.5, but there is a good trend of growth. Her blood sugar was also basically in the normal range. Of course, Annie’s parents are also beneficiaries, saying, “By helping Annie heal together, we have seen and repaired potential problems and conflicts in our family, and in the process, we have grown, so we should thank our Annie for giving us the opportunity to discuss family issues together.”
Indeed, changes in the family are fundamental to changing the illness, and the family’s awareness will keep them aware, reflecting and discussing in their future lives. I believe that Mr. Zhang’s family will use their own resources to change in a positive direction, because I believe that every family has its own energy, and we therapists are just a perturber and accompanying supporter when the family is blocked in the process of moving forward.