Structural Family Therapy in

Psychosomatic Illness

Treatment of Anorexia Nervosa and Asthma

Lee Combrinck-Graham, M.D.

EVER SINCE FRANZ ALEXANDER’S

of a model for psychosomatic ill-
which two serious psychosomatic illnesses
exist. If attention is given to restructuring
proposal
ness in 1935, the debate over the specificity the family system around one set of symp-
of psychic stresses in relation to particular toms, the other should also improve.
symptoms has been continuing and heated. This paper describes the family treatment
Such a specific model has among its follow- of a child who presented with chronic
ers those who have gone on to explore the asthma and anorexia nervosa. The
unique personality features of individuals emergency of the anorexia led to attention
with particular psychosomatic illnesses. In being focused on this symptom. The inter-
contrast, those who adhere to the nonspecific ventions to restructure the family concen-
models of psychophysiologic illnesses focus trated initially on the management of the
more on the psychic stress, and view the child’s weight. No specific attention was paid
physiologic expressions of stress as being to the asthma (this was left entirely to
specifically referable to constitutional and the pediatricians): nevertheless this too im-
genetic factors. proved remarkably.
Minuchin, et al.2-’ have proposed a Families of psychosomatic children have
nonspecific model for psychosomatic illness several features observed by
common
in children. According to this model, the Minuchin, et al.2-4 These are enmeshment,
expression of symptoms in a child is pro- characterized by poor boundaries between
duced by dysfunctional family interactions. individuals and between generations within
This model is nonspecific because it the family; lack of conflict resolution,
hypothesizes that a variety of psychosomatic particularly between spouses, so that the
illness (labile diabetes mellitus, asthma, and psychosomatic child’s symptoms often func-
anorexia nervosa) can be produced within tion in the avoidance of conflict; and over-
similar family systems. protectiveness, wherein all family members are
The model further implies that the treat- involved in a high degree of concern for each
ment goals for familes of psychosomatic other’s welfare. Clearly these constitute fea-
children will be similar, regardless of the tures of a system which will reinforce and be
particular psychophysiologic system affected, reinforced by the child’s symptoms. Treat-
since families of psychosomatic children ment for the child will involve restructuring
show similar characteristics. To test this the family so that the child’s symptoms no
hypothesis, one may look at one family in longer are necessary to maintain the system.

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Important steps in restructuring will be mark- tapered off eating until at the time of admission
ing clearer generational boundaries, remov- she weighed 83 pounds.
ing children from involvement in parental-
Other Symptoms
spouse conflicts, and encouraging success in
conflict resolution. Other symptoms had kept Nancy the focus of
medical problems in her family for almost a year.
For example, she insisted first that she could not
Case Presentation
see and later that she could not hear. With both

Nancy, an 1-year old girl, was admitted to the complaints, thorough examination revealed no
Children’s Hospital of Philadelphia after she had cause for the symptoms. Finally, the parents

refused to eat anything for a week. The younger confronted the child and told her that nothing
was wrong with her. The symptoms disappeared.
of two sisters by four years, Nancy had been
asthmatic since age one. Since age six, the asthma
had been so severe that she had been more or less Initial Examination
a chronic invalid. Concern about the asthma and
On initial examination in the hospital, Nancy
poor peer relations had led to visits to two
psychiatrists, one at age six, another at age nine. appeared to be very tall for her age, lying flat in
Neither experience had produced better control bed and talking in a squeaky voice as if very ill. She
was frequently tearf~tzl and complained about
of her asthma or better adjustment with her
peers. pains in the back, head, and stomach. Despite the
high pitch of her voice, which was difficult to
’
understand, she was quite friendly. Her main
The Asthma voluntary. topics were her devotion to her family
and her various pains. Her speech about these
Nancy was being maintained on a variety of was goal directed. Despite her reported wish to
medications for her asthma including prednisone die, she did not appear depressed. Rather, she
every other day. Tedral was given when thought appeared stubborn and determined.
necessary, and when Nancy requested a dose, her
parents would become alarmed. Asthma attacks
The Family
frequently occurred at night. Nancy’s mother knew
how to administer subcutaneous epinephrine. from a well-edzzcated, upper-
Nancy came
Often, during the crisis of an asthma attack, the middle class Protestant family. Her mother had
parents would argue about whether she should been a successful professional prior to her mar-
have more epinephrine, whether the mother had
administered it correctly, and whether or not to
riage. Since the marriage, the mother had not
worked and had occupied herself solely with
take the child to the hospital. concerns about the family, particularly her
In the year prior to her hospitalization, Nancy
had missed more than half of her school days daughters. She was overweight; because of her
because of illness. The possibility of sending her appearance, she did not go out at all except to do
the family shopping and errands for her daughters.
away from her family to a convalescent home for For more than ten years she had been &dquo;afraid&dquo; to
children had been raised and was strongly op- drive a car beyond the immediate neighborhood.
posed by both Nancy and her parents. She had She also had several medical problems including
never been away from her family overnight.
hypertension with top pressures around 220/110,
for which she took several medications. She °

The Anorexia tyrannized her family with her moods. She would
frequently withdraw to her room, leaving the rest
Six months prior to admission, Nancy weighed of the family worried about her blood pressure
130 pounds. At that time, she had a viral illness and wondering what they had done wrong. Food
and lost five pounds. She then decided to go on a had particular importance in the mother’s family
diet in order to be able to get into preteen of origin. If people loved you they would eat a
clothing from the chubby sizes that she was then lot; if they didn’t eat a lot, they didn’t love you.
wearing. Two months later, when checked by her She complained that her husband didn’t eat
pediatrician, Nancy weighed 108 pounds, which enough.
was deemed an ideal weight. She nevertheless
Nancy’s father was a professional man in
persisted in dieting. Two months after the check- business for himself. He had been extremely
up, she was hospitalized at another hospital for successful and able to provide amply for his
pneumonia. During this hospitalization, she re- family. He had a healed peptic ulcer which was
fused to eat at all until her parents demanded usually ignored. At stressful times he would chew
that she eat. After her return home, she re- antacids. He was an extremely solicitous man,
mained bedridden and demanding. She gradually devoting much attention and care to his family,
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 especially to his wife who frequently rewarded Therapeutic Goals
him with an angry retort or a withering look. By
his overprotectiveness to his wife, he gave the The goals of therapy with this family were 1) to
get Nancy out of the emergency caused by her
’

message that she was incompetent to do any-

refusal to eat, 2) to change the significance of the
thing-to drive into the city, to look after her
children, to hold down a job, or even to look after symptoms so that Nancy’s not eating was viewed
herself. not. as a consequence of illness, but as disobedi-
Nancy’s 14-year-old sister, Gail, was reported to ence, 3) to draw a boundary between parents and
children, and 4) to loosen the hold of the parents
be &dquo;normal.&dquo; However, she appeared considera-
on their children so that they would be freer to go
bly older than her stated age, wore too much out, make friends, and be healthy, growing girls.
makeup, had a difficult complexion problem, was
overweight (though not as much as her mother),
and did not have any friends. She tended to have Summary of Treatment (reflected in weight
a parental attitude toward Nancy. She related to
her mother like a sister, and the two of them
gain reviewed on graph):
frequently joined together to deride either father In 24 hospital days and Il outpatient family
or Nancy. sessions over a period of 10 months, this anorectic
It was, then, an enmeshed family with poor to child, who had lost more than 50 pounds, gained
absent generational boundaries in which alliances 50 pounds and grew four inches. Three months
between a parent and child were frequently after treatment ended she began to menstruate.
formed against the other parent. At times of In addition, though the therapy focused on
conflict in the family, Nancy would attract atten- eating and weight control, the patient had only
tion to herself with some complaint, thus divert- one asthma attack during the period of treatment

ing the family. Parents would often fight about after she left the hospital. Furthermore, though
the best way to manage the symptoms, which previously severely restricted in her activities, she
would often become serious before proper inter- began to swim every day, ride a bicycle, and
vention was made. attend gym classes in school. She had a basketball

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net installed in thefamily garage so she could gent on gain of
least half a pound a day.
at
practice after dinner. Finally, she was asympto- After the of this, Nancy had
announcement
matic for so long that she was permitted to have a
an asthma attack necessitating the adminis-
dog in the household. Two months after therapy tration of intravenous fluids. As a result of
ended Nancy was discharged from treatment by
her allergist since she had no further symptoms. this treatment, she gained 0.9 pounds, was
Very striking, too, was the change in Nancy’s congratulated, and told that her parents
personality. She began treatment a hypochon- could now visit. She became so angry about
driacal, complaining, immature child. By the end the weight gain that she swore that she
of treatment, she was outgoing, witty, and coping
would not have another asthma attack. She
actively with peer issues of a 13-year-old-girl.
had no further attacks while in the hospital.
Crucial in the At discharge, her pediatrician was willing to
Steps Therapy
discontinue all maintenance medication for
In the asthma.
Hospital
On the 13th hospital day, a therapeutic
Essentially the hospitalization was treated
crisis. There main
family lunch session was held. The entire
as a were two objectives of family was asked to bring lunch to the Child
treatment during this phase. One was to Guidance Clinic, and to be sure to bring
shift the view of the symptoms from an what they considered an adequate lunch for
&dquo;illness&dquo; to seeing Nancy’s behavior as dis-
Nancy. Nancy was brought from the hospital
obedient and unloving. Tlle second was to dressed in street clothes, and the family sat
see that the family had enough control over
down to lunch with the therapist and pedia-
the eating that they could work with their trician.
daughter at home. Such a family lunch session has become an
In the hospital Nancy saw herself as
institution in the family treatment of
seriously ill, complained bitterly, and said anorexia nervosa.~°~ It provides an opportu-
that she could not walk. She would not
nity for altered family interaction around the
participate in caring for herself. With the symptom with the goal of 1) changing the
nursing staff, the therapist began a regimen concept of the identified patient in the
which required that Nancy be out of bed for
an hour three times a day and that demands
family, 2) transforming the eating problem
into an and 3) disen-
interpersonal problem;
for others to do things for her be turned the parents from the child’s eating
back with a suggestion that Nancy could
gaging
behavior as a conflict-detouring device.
manage for herself. During the last half of
her hospitalization in a regular children’s During the lunch session, everyone ate
with cheer and conviviality except Nancy,
medical ward, Nancy wore street clothes to who sat next to her mother and provided
emphasize her good health. constant distraction from the conversation.
After everyone had finished, the therapist
The purpose of this outpatient phase was observed that it was time for Nancy to eat..
to stabilize and further the structural Since Nancy was only 11, the therapist
changes which had begun in the hospital thought that the adolescent issue of au-
through fostering more complete and tonomy was not yet a strong one. The focus,
instead, was on the effectiveness of the
competent executive functioning by the parents. They were instructed to feed their
parents. child. The confrontation of child and par-
ents over eating created a crisis. This ena-
Initially, the care of Nancy’s asthma was bled the therapist to drive home the point
left entirely to the pediatricians. An early about disobedience, the strength of this
attempt to establish a behavior paradigm for apparently frail child, and her hating attitude
weight gain (the conventional one of restric- toward the good nurturing intentions of the
ing activity was not appropriate for this child) parents. But beginning to get Nancy to eat
was to make visits from the parents contin- divided the parents. The father shouted and

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threatened and the mother laughed at him. fostering more complete and competent ex-
When she in turn cajoled, he told her that ecutive functioning by the parents. They
she would never get anywhere that way. The were expected to manage Nancy’s weight.

therapist pointed out that Nancy was strong We worked with them around issues nf
enough to counter either one of them alone conflict which they had not previously been
and to divide them, as well. They finally able to resolve themselves, providing ways of
worked together to force her to eat in a dealing with conflictual situations other than
convincing display of teamwork and unity. over a symptomatic child. As a further goal,

As can be seen on the graph, this lunch- the children were encouraged to interact
eon session was a turning point in the more freely as sisters and to focus more
treatment of the weight problem. After this,
the parents were willing and confident about Minuchin, et al. have proposed a
feeding their child, and, perhaps ironically, nonspecific model for psychosomatic
Nancy appeared convinced of her parents’ illness in children (in which) the
...

genuine regard for her. Certainly the use of

her symptoms as a conflict-detouring mech- expression of symptoms in a child is
anism for her parents had been dramatically produced by dysfunctional family
confronted. interactions.
On the 24th hospital day, Nancy weighed
79 pounds, a six-pound increase from her attention on their activities outside the fam-
in-hospital low of 73 pounds on the 12th ily.
hospital day. Since there had been a steady Shortly after Nancy’s discharge from the
gain for one week, and since the family felt hospital, the family planned a vacation trip
they could manage at home, Nancy was away. The therapist agreed that this was a
discharged. At the time of discharge, the good idea but enjoined that if Nancy had not
family was instructed to be sure that Nancy gained the required amount of weight the
gained at least three pounds per week. If whole family would have to cancel the trip.
not, she would have to be rehospitalized This was yet another statement that Nancy
until they could get better control. In addi- was strong enough to organize the family if

tion, they designed a daily schedule for they did not undertake to organize her.
Nancy. which involved getting up and being Nancy’s parents accepted this and added to
dressed early in the morning, going out to it the contigency that Nancy, who continued
swim, and being outdoors most of the day to walk and talk like an invalid, would have
when possible. It also included visits with to stand up straight and talk normally. This
friends. This scheduled was designed to was achieved in time for the family to have a
underline Nancy’s basic health. pleasant trip a month after discharge,
In drawing generational boundaries, the
Outpatient Phase therapist suggested that the two girls be
allowed to interact freely. Previously, the
The outpatient phase of management con- parents had interfered in all arguments in
sisted of 11I family sessions at intervals order to protect Nancy because of her
ranging from one week early in the therapy illnesses. The older girl had complained
up to four months. The average interval was that she was never allowed to treat her sister
one month. The
infrequency of the visits was like another person because of her delicate
set by the family, who lived some distance health.
from the Clinic. As long as things were The parents were seen alone in parts of
progressing well, the therapist saw little several sessions. During these times, we
reason for more frequent visits. discussed the specifics of their disagreements
The purpose of this outpatient phase was over child rearing and other interspouse
to stabilize and further the structural changes issues. The mother was encouraged to get
which had begun in the hospital through out of the house more. She refused to get a

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job but did take up Transcendental Medita- Thefamily, though alarmed by this
tion. In addition, attention was devoted to episode, was proud of the way they all

the mother’s self-image. Although she was handled it, looking upon Nancy as a healthy
very much overweight, she was a striking child with occasional asthma attacks.
woman who dressed well. The therapist A therapeutic intervention at this point
constantly commented favorably on her ap- involved two things. The parents were asked
pearance, bringing confirming comments to set up a procedure to follow for managing
from her husband. The couple began to Nancy’s asthma attacks. This was to include
increase their social activities, leaving the clauses ranging from when to administer the
girls home alone for the first time in their medication and take the child to the hospital
lives. to how to keep the mother calm so that she
As therapy went on and Nancy’s weight did not further upset Nancy. After this, the
gain was established, the therapist attempted family gathered to plan for the next visit of
to diffuse the focus on the younger daughter the grandmother. The purpose of the plan-
and include other family members. Gail’s ning session was to decide how to take care

problems came to attention. She was worried

about her complexion and her weight. The
therapist arranged a weight-losing
program,
This (result) supports the hypothesis that
the results of which were to be kept psychosomatic symptoms in children
confidential. That Gail was on a diet was serve a function in maintaining
made known to the rest of the family so that dysfunctional patterns in the family
weight control became a family issue, not system, and that when the system is
just limited to Nancy. After the diet was restructured to alter these dysfunctional
started, Gail began to struggle with her
patterns, the psychosomatic symptoms
parents over her right to exercise con-
trol over what she ate. As much time in improve regardless of the physiology of
the sessions was spent discussing aspects of the illness or its expression.
weight control with Gail as with Nancy. This
shifted the attention of the parents so that at of the overwhelming demands made on the
the end of the treatment they were more mother by her family. The father was in-
concerned with Gail’s problems with a structed to watch for the signs of his wife’s
moody adolescence than with Nancy. distress and to take the girls out somewhere
at this point. If that was not possible, Nancy
The Asthma was instructed to have a slight asthma attack,

As mentioned, the asthmawas not treated

enough to summon her mother away from
the stressful situation to set up the vaporizer.
per After the one attack in the hospital,
se.
The purpose of this instruction was to
Nancy remained asthma free for about six change the connotation of the symptom
months. Just before an important holiday from an alarming one to a protective one. It
when the family was anticipating a visit from also implied that the child could control her
the maternal grandmother, Nancy had a attacks. Naturally Nancy was incredulous,
severe asthma attack. The mother, who had
but the family enjoyed the grandmother’s
gone out despite the fact that Nancy was visit, and Nancy did not need to have an
home with a cold, was called by the house- asthma attack. She had no further attacks up
keeper to return. She became alarmed and to the time of the most recent follow-up-
called her husband who came home early almost a year later.
from work. Together they decided that she
should be taken to the hospital where she
was treated in the emergency room with
Summary
intravenous fluids, epinephrine, and seda- This account of the treatment of anorexia
tives. nervosa in a child with asthma stresses the

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 importance of restructuring the family sys- References
tem. Even though the treatment was focused
et al.
1. Liebman, R., : An integrated treatment pro-
on the management of one psychosomatic gram for anorexia nervosa. In press.
2. Minuchin, S.: Families and Family Therapy: A
problem (anorexia), the other problem Structural Approach. Boston, Harvard University
(asthma) improved remarkably as well. This Press, 1974.
al Psychosomatic illness in chil-
3. Minuchin, S., et .:
supports the hypothesis that psychosomatic dren : a new conceptual model. Mimeograph.
symptoms in children serve a function in : Anorexia Nervosa: A Successful
et al.
4. Minuchin, S.,
maintaining dysfunctional patterns in the Application of a Family Therapy Approach.
Presented at The American Academy of Child
family system, and that when the system is Psychiatry, Washington, D.C., October, 1973.
restructured to alter these dysfunctional pat- et al.
5. Rosman, B., : Family Lunch Session: An
terns, the psychosomatic symptoms improve Introduction to Family Therapy in Anorexia
Nervosa. Presented at The American Academy of
regardless of the physiology of the illness or Child Psychiatry, Washington, D.C., October
its expression. 1973.

The Competent Infant: In brief, this volume provides

Research and Commentary a complete overview of an exceed-
ingly active field of research, with
Edited by L. JOSEPH STONE, illustrations of the many problems
H. T. SMITH, L. B. MURPHY.
under study, the methods being
New York, Basic Books, 1973. utilized, and the kinds of results
1283 pp. $30.00. and theories existing at the date
of its compilation. As a reference,
The editors, who are distin- it should be available to all who
guished practitioners of the study are seriously interested in research
of child development, here present in child development. As back-
202 papers to illustrate the com- ground for pediatric practice, this
plexity and the advances in this volume has undoubted value,
field. The papers are grouped ac- though whether a practicing physi-
cording to individuality and de- cian could be expected to digest
velopment, prenatal and perinatal the whole twelve hundred pages BOOK REVIEWS.
development, the capabilities of the is doubtful. One who wishes to dip
newborn, development during year and choose mav well be rewarded
one, the effects of depredation by most of the papers in this
and enrichment and socialization. selection. Scanning the editors’ com-
Included are some classic papers ments for each chapter will give
on the development of other or- the pediatrician quick briefing on
ganisms such as Harlow’s work on the latest developments in Child
mother-infant separation in mon- Development. All in all, a major
keys, Riesen’s work in visual dep- achievement; the individual must
rivation in monkeys, and studies decide as to whether he deems
of kittens, sparrows, and even the it a necessary addition to his pro-
snapping turtle. The editors pro- fessional library. MORTIMER GAR-
-

vide commentaries in which they RISON, PH.D., Philadelphia, Pa.

endeavor to review the respective
fields of study. (Book Reviews Continue on page 867)

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