Journal of the American College of Nutrition, Vol. 18, No. 2, 186-188 (1999)
Published by the American College of Nutrition
Anorexia Nervosa Treated in a Foster House Setting: A Case Report
Moria Golan, PhD
School of Nutritional Sciences, The Hebrew University of Jerusalem and Nofit, Eating Disorders Treatment Center, Israel
Address reprint requests to: Moria Golan, PhD, Ganey Hadar, P.O. Soreq 76830, Israel
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ABSTRACT
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A case report of 17 year-old restrictive-anorectic girl is presented. The patient was treated in a foster family. A novel setting for treating clients with severe anorexia nervosa will be described and discussed. The treatment was mainly oriented toward the narrative approach. However, cognitive-behavioral techniques as well as psychotherapy and antidepressants were employed as well.
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INTRODUCTION
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The increased prevalence of anorexia nervosa (AN) in Western societies has encouraged many developments and the implementation of new approaches in the treatment of the disorder [1]. Many patients are hospitalized in psychiatric departments where they often adopt others’ symptoms and frequently relapse following discharge from the hospital. Foster care can be an alternative to hospitalization. It is a professional treatment resource which is as close as possible to the normalcy of typical home surroundings, and one used widely in the psychiatric domain [2]. It can provide the appropriate environment for diminishing the anorexic experience, especially when it is available to the narrative approach. The narrative approach assumes that our lives are constituted through narrative. To deconstruct the stories which persons narrat their lives by, Michael White has proposed to do this deconstructing through objectification of the problem [3]. Objectification engages the individual in an externalizing of conversations relevant to his or her problem, rather than in internalizing conversations. Externalizing conversations are crucial so that the patient may experience an identity distinct from his or her view of himself or herself in order to clear the way for distinguishing areas in the patient’s life not co-opted by this view, thus exploring alternative, positive versions of who he or she might be. Externalizing conversations encourage persons to verbalize how the problem impacts on his or her life (including emotional states, relationships, social and work spheres and the like) with emphasis on how the problem has affected his or her "view" of himself or herself and his or her relationships. The individual is then invited to "map" the influence this view or perception has on his or her live.
Using the narrative approach in treating AN enables patients to separate themselves from the "totalizing" stories that are constitutive of their lives and to orient themselves toward those aspects contradicting these perceptions. This approach helps the patient to engage in change rather than guilt or blame, which are often the dominant feelings among patients with anorexia nervosa.
The foster family setting serves as an therapeutic environment in which intensive externalizing talks can occur; the "normal" behavior of family members serves as a counter behavior to the anorectic one, as well as a model of healthy attitudes toward food and eating. The containing and holding environment and the presence of caregivers with therapeutic backgrounds (a clinical dietitian, in the present case) gives the patient an opportunity to change maladaptive patterns of interaction.
The following is a case study of a 17-year-old girl with severe anorexia nervosa, of the restricted type. After a three-month hospitalization, she was transferred to a foster family for a period of two months. The process of her recovery will be described.
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PATIENT PERSONAL DATA
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D, the youngest of three children in the family, developed anorexia nervosa at age 16. She was 1.52 m tall and weighed only 35 kg—a 32% reduction from her ideal weight. The low weight was accompanied by severe weakness and amenorrhea. Diagnosed as restrictive anorectic, she was hospitalized in the adolescent department of an Israeli general hospital.
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HOSPITALIZATION COURSE
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Hospital treatment included refeeding a 8.4-kilojoules (2000 calorie) diet, prescribed by a clinical dietitian and regulated by the department nurse. The medication treatment included Favoxile (an antidepressant), and the patient participated in individual psychotherapy sessions with the department psychiatrist. After three months, she gained only three kg, and the psychiatrist felt her weight phobia was still a major problem determining the avoidance behavior, although the patient acknowledged the disorder. As is common with anorexia nervosa patients, she engaged the department team in constant confrontation, including throwing food into the garden, and ended up with punishment (transfer to a less comfortable room). D felt she would do anything to regain her freedom. At this point, her father decided to permit her discharge from the hospital and transfer to a foster home managed by a clinical dietitian.
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FOSTER HOME COURSE
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Admission to the foster house was carried out after D signed a special contract with the family. She agreed to gain one kg a week, allow her caretakers total control over her diet, to integrate herself into the foster family and not to leave before the target weight had been reached. During this period, she continued her individual psychotherapy with the hospital psychiatrist. The family refused to engage in family therapy although this was strongly suggested. While staying with the foster family, a 12.5-kilojoules (3000-calorie) diet was prescribed, and, when necessary, behavioral techniques were introduced to eliminate anorexic behaviors, among them, crumbling food, hiding and throwing food, not finishing the food on the plate, eating very slowly and so on. Cognitive restructuring was a useful tool to address dysfunctional thoughts and maladaptive behaviors.
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STAGES IN THE PROCESS OF RECOVERY
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Gaining Faith and Externalizing the Illness
During the first appointment the foster mother (a clinical dietitian) explored the nature of the illness, reviewed the effects that AN was having in the various domains of the life, including social, emotional, intellectual, familial and physical. Externalizing the illness helps to remove guilt while empowering the patient to develop hostility against it and join the battle against the illness. The most important task of the foster family was to gain D’s faith as well as recruit her to fight the illness. Later, efforts were devoted to externalizing the illness when confronting it in daily life: difficulty in breathing upon exertion, embarrassment during visits by friends, distress in a restaurant, concentration difficulties when reading or performing school work and, most of all, facing loneliness.
Situation in the Foster Home
At the beginning, D handed over control of her diet, but argued when food looked oily or fat was added. She argued less when she learned to trust the family. Her moods fluctuated from feeling lonely to feeling choked and constrained by the demanding atmosphere. The foster family insisted she eat the same meal as the others at the table, conduct fundamental to the process of experiencing normal eating habits.
Idealization
The containing and holding environment, isolated from the parents’ house and difficulties, enabled D to feel safe and gain weight according to the original agreement. This period was characterized by the establishment of a strong relationship with the dietitian who empathized with her difficulties. This, in turn, was accompanied by an idealization of the foster mother, motherhood and the extent to which she saw herself as part of the family unit. At this stage she made the decision between life and death. She chose to live.
After four weeks, D’s parents came to the foster home for a visit. It was a pleasant meeting with a minor discussion about the anorexic symptoms, but with no sharing of the difficulties.
Realization
As time went by, D gained weight and experienced loss of control over her hunger and, thus, was forced to acknowledge her impotency in the face of the disease. This period was characterized by recognition of her idealization of the foster family. The ambivalence between loyalty to the healthy self and foster family and loyalty to the illness evolved; gaining control was the main issue. Horseback riding and dance therapy were used to develop a sense of self-control. Reconnecting with the self, especially the body and the spirit/self/mind, i.e. getting a haircut, wearing earrings, dealing with anger, reestablishing relationships with others, was encouraged. The target weight was achieved. Anorexic eating behaviors were minimized. Her parents were prepared for D’s return by the psychiatrist.
Back to the Natural Environment
After six weeks with the foster family, D was ready to visit her parents’ house. She found it very difficult to eat with them and felt they were "policing" her. She still was recruited by the illness in her home environment. Only when her family ignored her anorexic behavior and she acknowledged to herself that anorexia does not make her super or exclusive, did recruitment by the disorder diminish.
Finding a Sense of Peace Within Herself
After eight weeks, D left the foster family, having attained her target weight of 40 kg but still rigidly controlling her diet. Several follow-up visits in the next months were aimed at gaining her flexibility and maintaining her achievement. While reauthoring her life, D elevated her self-esteem, engaged in new commitments, work, study, driving lessons, boyfriend, and finally, gained a sense of inner peace.
The foster family accompanied D through the time of separation, from the chaotic period of feeling no sense of self-worth—helping her move into a phase of enhanced autonomy, individuation and transformation—to a feeling of self-control, thereby aiding her in constructing a more worthy person in the eyes of self and the society.
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DISCUSSION
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The case described suggests that a foster family can be the answer for some anorexic patients. Using the narrative approach to unmask the illness and enhance externalization enables the patient to acknowledge the destructive nature of the disease, take a position and counter it. The foster family, if appropriately aware, trained and dedicated to understanding and combating this disease, can actively and intensively treat the illness. They can furnish the patient with a normal environment, thereby forcing "normal" behavior with which to cope with the absurd situations being caused by the illness. Moreover, in this containing environment, the patient has the possibility of slowly replacing acting-out with verbal communication. The treatment of the anorexic patient is always a difficult and extensive task [4], which involves an extremely subtle balance. The foster family must be supervised by a well-trained psychologist as an aid in addressing the countertransference issues and in strengthening the family while it and the patient cope with the severe disease.
Attention must be paid to the biological children of the foster family [5]. They must be trained to adjust to the foster care. Learning to share their parents’ attention during this period is crucial. Reinforcement of the family unit could be characterized by activities such as a vacation, outings and similar undertakings. The relationship between the psychologist or the psychiatrist and the foster family in this setting should be explored.
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ABSTRACT
INTRODUCTION
