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Dr. John Sargent and Dr. Ronald Leibman, who worked with Salvador Minuchin at the Philadelphia Child Guidance Clinic, have divided family therapy into three phases. In the initial phase, we evaluate the patient and the family and establish the therapeutic relationship. For low-weight anorexic patients, we devise a contract that identifies the problem, then spells out in specific terms the treatment’s goals and the methods for achieving them. The contract usually focuses on the patient’s weight; we hold off dealing with other problems, such as marital difficulties, until a later time. The first thing is help the anorexic gain weight, or the bulimic to break her binge-purge cycle, and improve her psychosocial skills.

During the assessment, we get the facts: ages, educational level, and the nature of the family’s social interactions. We also want to know how each member perceives and defines the problem. What factors affect the situation: physical illness, social issues, religion? What was the family like before the illness? What stressors triggered the problem? Who is closest to whom? Is there an extended family – grandparents, for example? Who outside the family plays important roles in their lives? Teachers? Friends? Employers?

We then probe a little deeper. What are the patterns of interaction: Who communicates with whom? Are some family members “friends” and others “enemies”? How strong is the marriage? Is the couple satisfied? Do they agree on parenting strategies? How flexible is the family – are roles rigidly laid out? Are members oversensitive to each other, or detached and distant? How strong are their social networks? Are there financial or other medical problems? Do the children have family responsibilities that fit their stage of development? To what extent is the family aware of the illness? What are its fears, beliefs, and attitudes about it? The middle phase of treatment begins once the symptoms are more under control. We now shift our focus to the patient’s problems with her emotional and physical development, especially as they relate to unresolved family conflict. We identify the stresses that might have led to the weight loss or bulimia, and find other ways of dealing with them. It helps if we can relate symptoms to family processes -for example, seeing that a binge might occur if the patient feels unloved or pressured in some way.

It often happens that as the patient gains control she experiences a flood of new feelings. A little success might bring up fears about handling new tasks. We caution family members to expect that their daughter or sibling might have feelings of depression, or of ineffectiveness and rejection. If we’re not careful, the family might focus on these new problems and become even more enmeshed than before.

During this second phase, we help the family learn how to tolerate open conflict, and show them new ways of resolving problems. We stress that the patient’s separation from the family is an inevitable and healthy process – but perhaps a painful one for everyone involved. It helps if the parents learn to deal with each other directly. Once they do, the patient will feel less protective and can work on her relationships with her friends. As Richard Schwartz puts it, she can “grow up” without having to “grow away.”

This second stage is critical, since it marks the transition from focusing on the disorder itself to focusing on the broader issues. When therapy is working, everyone wins. The parents learn new ways of helping their daughter grow; the patient shows she can take responsibility for herself and that she has earned the right to “declare independence” from her family.

In the final phase, we work to “wean” the family from therapy. If we have identified problems that still need work – the parents’ marriage, for example – we steer people toward therapy designed to address those issues. At this point, the patient’s individual therapy might focus on how she can change the way others in her family treat her, to keep harmful interactions to a minimum. Just as important, we identify those things that might not change. Forewarned, as they say, is forearmed.

*105/35/5*

Crab, Sweet Corn and Celery Soup

75 grams corn kernels

250 ml vegetable stock

1/4 teaspoon sea salt

1/4 teaspoon pepper

1 teaspoon Chinese wine

50 grams crab meat

1 stick celery, finely chopped

1/4 teaspoon corn flour

1 egg white

Fresh coriander leaves

Place the corn kernels in a blender and blend until coarsely chopped. In a saucepan, bring the stock to the boil with the corn. Add the seasonings, wine and crab meat, and chopped celery. Thicken die mixture slightly with the corn flour and finally, pour in the egg white in a steady stream, and beat. Remove the soup from the heat immediately and garnish with the torn coriander leaves.

Creamy Pumpkin and Soy Milk Soup

1 whole pumpkin

2 litres water

3 cloves garlic, chopped

1 onion, chopped

1 piece ginger

1 cup soy milk

2 tablespoons tamari

Sea salt to flavour ;

Chop pumpkin and boil in water. When tender, remove pumpkin from water. In a food processor place a small amount of chopped garlic, chopped onion, the ginger and a few chunks of the pumpkin. Add soy milk and blend in the food processor until you have a slightly runny consistency.

Place back in the pan and then blend the rest of the pumpkin. Once all the ingredients have been blended and placed in the pan, add tamari and sea salt, and simmer. Add water if you require less thickness in your soup. Serve with a thick dollop of natural acidophilus yogurt (if desired).

Energy Tonic Soup

8 dried shitake mushrooms

1 slice dried Chinese licorice root

2 cloves garlic, crushed

1 onion, chopped

1 carrot or sweet potato, chopped

1 slice fresh ginger

1 dried hot chilli pepper

1 handful basil leaves

3/4 cup pearled barley

6 cups vegetable or chicken stock

1 teaspoon olive oil

2 teaspoons barley miso

Chives, chopped

Soak the mushrooms in hot water until soft. Discard the stems and slice thinly, save the liquid. In a large saucepan, combine ingredients (except olive oil, miso and chives), plus reserved liquid. Bring the soup to the boil, reduce heat and simmer covered, until the vegetables and barley are tender (about 1 hour). Remove from heat and add olive oil. Mix miso with a small amount of water, and then add to the soup. Serve hot, sprinkled with chives.

*224/34/5*