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Locating the presenting problem in the broader family context revealed that the family was in the process of negotiating some significant changes.
Around the onset of Tanya's pronounced weight loss, her older sister, Roslyn, had moved away from home to begin medical studies at university. Roslyn had previously been considered the rebel of the family but was now clearly labelled as the 'golden girl' who would make them all proud with her academic success. Family roles and the theme of economic success were identified.
Mr. Barret had recently received a promotion which necessitated moving to another city.
Mrs. Barret had left her job as a nurse and had not been working for the nine months following the family move.
Gender themes were becoming evident as Tanya spoke of how personally she was identifying with her mother's loss of professional role. While there were numerous family changes that could inform hypotheses about her symptoms, my primary focus was the operation of family triangles in dealing with anxiety. Tanya expressed her triangled role in her parents' issues as she spoke about their emotional life. She described the stress of her father's work and reported passionately on her mother's loss of status since giving up her nursing job. She perceived her mother's life as empty, and she herself felt similarly empty and directionless.
The fusion in nuclear family relationships was striking, with family members reacting to either comfort or criticise each other.
During the sessions, the six year old daughter Liz passed tissues to those who looked upset, or distracted by using puppets from the play box to bring some humour into the room.
I reflected to the family just how closely 'wired' to each other's feelings they all were and how readily they seemed to switch from their own issues to focus on the emotional intensity of others. Questions were asked that encouraged an awareness of this fusion, for example:
[To Tanya]. 'I know you've become an expert at being the emotional voice for your parents but what would you say, just this once, if you could speak for your own needs?' [To Mr. Barret]. 'Do you have any sense of when you first started to take Tanya's symptoms so personally - as if they were directed at hurting you?' Mrs. Barret spoke of how their eldest daughter Roslyn had complained of feeling suffocated by being at home and how they had hardly seen her during her last few years of high school. When Roslyn was at home her relationship with her father had been highly conflictual. Now that she was at medical school Mr. Barret spoke of how proud they all were of her. He had tears in his eyes as he spoke of how Roslyn now had the chance to achieve what he had not been able to. Each of the children, to varying degrees, appeared to be triangled into their parents' emotional issues. While Roslyn and Liz were currently occupying symptom-free roles in diffusing parental anxiety, Tanya seemed stuck in a symptom-focused dance with her parents' neediness.
Nuclear family triangles were tracked around family members' responses to Tanya's eating patterns.
A typical sequence would be:
- Mrs. Barret watching Tanya's eating behaviour closely, with Tanya becoming increasingly withdrawn.
- Mrs. Barret would accuse Tanya of bingeing and purging, with the latter responding in tears, saying that nobody in the family would trust her.
- Mr. Barret who had been hearing a daily account of his wife's suspicions, would begin yelling at Tanya, saying what a disappointment she was to him.
- Mrs. Barret would feel sorry for her daughter and move closer in support.
- At this point, when Tanya's symptoms threatened to increase distance and tension in the marriage, Mrs. Barret would suggest ways to her husband and daughter about how they could make up.
- Tanya continued to refuse to eat with the family but would set up a joint outing for herself and her Dad.
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