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CAT and the Cultural Formation of a Case of Anorexia Nervosa: An Italian Case Study

Cristina Fiorani and Marisa Poggioli, 2005. CAT and the Cultural Formation of a Case of Anorexia Nervosa: An Italian Case Study. Reformulation, Autumn, pp.13-17.

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Aims

The aim of this case presentation is to demonstrate a link between the surrounding culture and our subject’s internalised representation of it, which determined the way she felt she ought to be in order to be admirable. This will be done from the perspective of Cognitive Analytic Therapy (CAT). We will be attempting an accurate description of Maria’s inter- and intra -personal problems through her preoccupation with weight, food, and her self imposed, unattainable, perfectionist standards.

This presentation will illustrate the internal roles adopted by Maria as an individual, the influence of her family in the formation of her inner dialogue and, in its turn, the infl uence of the culture on the family.

CAT is based on a social concept of the self and this case demonstrates how Maria had interacted reciprocally with her family and had internalised that experience. In CAT social meanings and cultural values are intrinsic to such internalisation and are seen as contributing fundamentally to the dynamic structure of the self.

We will examine Maria’s ability to hypothesize an image of herself as it might exist in the minds of others, and how she subsequently feels about herself in relation to how she thinks others judge her. We will also demonstrate how Maria is bombarded with messages about how the shape of her body equals her worth as a person by which process her sensitivity to shame has been heightened and has led to her to extreme dichotomous thinking in situations which she finds stressful.

Presenting problem

Maria was referred to the therapist who works for the local “ Servizio Sanita Publica” (The Italian State run health system) by the doctor/dietician at the local hospital. Her parents had brought her to the service because of their concern with her rapid weight loss in the past few months.

The doctor’s assessment resulted in Maria being hospitalized as her clinical tests were worrying. Her BMI was 14. She did not self harm apart from reducing her food intake. She was hostile to the doctor and refused to consider any sort of change in her present eating habits. She had stopped menstruating and had medical complications related to excessively low weight. She was not administered any medication during the therapy, but had regular medical checkups. The doctor invited the therapist to make contact with Maria at the hospital.

Presentation at Initial Interview

On first meeting with the therapist, Maria made it quite clear that she had no intention of participating in any programme that would make her fat. She was angry with her parents for forcing her to come. In Maria’s perception her parents and the doctor were united in trying to make her fat. She was adamant that her weight was not a problem, rather her parents interference was the problem. She said her parents wanted to control her life in every way, and what she ate had become a point of confl ict. Maria described feeling overwhelmed, as if she was “being squeezed into a corner”.

Maria had long blond hair and was described as “a beautiful girl” by the therapist. She presented meticulously dressed, in the latest fashion. Her style of dress emphasized her thinness, her clothes being short and tight. Her posture remained aggressive, as was her speech; she sat on the corner of the chair, extremely tense.

The therapist explained that it was up to Maria whether she came or not and that it was not her intention to coerce her to eat. It was stressed that it might be useful to her to have somewhere where she could come to be heard, no strings attached. The therapist stated that she would not be discussing food intake with her as this was already being done with the medical staff.

Maria was invited to write the story of her family. She wrote about her parents relationship and how her father had chosen her mother because she was so thin. Her mother had then become obsessed with dieting in order to keep him and had even dieted while pregnant with Maria. Her father had always hated fat women, his own mother had been a model and felt it was essential for a woman to be thin. Her aunt had been fat and had been crazy about it, going on a strict diet in order to attract a man, she now ate only fruit and vegetables. Her young son was fat and is on a diet. Maria wrote that although her father loved thin women he wanted Maria to be fat so that she stayed at home with him and did not get married.

She had been fat as a little girl but had dieted in order to be appreciated. Now she felt as if her only choices were either to be fat, like father wanted, but hate herself, or to be thin, like she wanted, and end up being sent to hospital.

Relevant Background

Maria lived with her parents and paternal grandmother in a small provincial town in northern Italy and attended a specialized senior school. She was doing well and was top of her class.

Her parents have the “Diploma di Scuola Superiore”, which is pre-university level. Her mother works in a bank and the father is a farmer. He employs others to do the work for him. Both parents are well dressed with particular care given to being fashionable, and are very aware of “la bella figura”. By Italian standards they are a well off middle class family.

Her mother was very thin, her father of normal weight. The topics of food, weight and eating have always been a family preoccupation. Maria remembers having to be pretty when she was a child and being made to wear a girdle for her confirmation so that she would look thinner; she was 8 years old at the time. Her paternal grandmother was once in the line up for Miss Italia and is now 70. She exercises, diets and does not want to age.

Comments on her weight and about her future prospects as a woman had affected Maria and her belief that she would be rejected by others unless she was thin. These comments made her worry that she might “lose control”. Maria had her weight monitored from an early age; if she gained weight she was disappointed with herself. Her parents are very critical of Maria telling her, and the therapist, that she “is not normal”. Maria summed up her view of her parents as a battle, she felt that in order to exist she had to win the battle, if they won then she ceased to exist. She felt that they had taught her that there was no such thing as an equal relationship.

Cultural Expectations in a Small Provincial Town in Northern Italy

There is convincing evidence that the praise and support that we receive from others as signs of being accepted and valued are physiologically regulating and impact on stress hormones and various neurotransmitters likened to positive affect (Cocioppo et al 2000, Schone 1994,2001 in Gilbert e Miles 2002). Miller (1981) also describes the importance of parental relationships in shaping the social brain. It can be said that social values shape both our social and personal values. The brain, the mind and human emotions cannot be understood in isolation from social context.

Italian culture is similar to other modern western cultures in that the media glorifies thinness in women in an explicit way, no subtle messages here. The Italian ideal for a young woman is to be excessively thin, equated with being attractive to the opposite sex. Normal weight girls are reported by the media as being less attractive, and the propensity for weight gain at puberty of the female is seen as problematic. It is still also the case for a woman that after a certain age being single is viewed as negative and that having a boyfriend and eventually getting married add to her status. Italians are, as a culture, very conformist. In order to be considered attractive women must be thin and wear the latest fashion. At the senior school being accompanied by a boyfriend adds to status.

If a person fails to measure up to expectations the fault is seen to lie within individual who is held responsible for not conforming. Not to diet or exercise in order to acquire the desired weight and shape is as shameful as it implies laziness and a loss of control. It is a society that places particular emphasis on how attractive one is to others rather than on inner values. Italy as a nation is a visual experience and one is rewarded for fitting into the mores of what is considered appealing. An attractive girl apparently gets all the prizes.

Theoretical Considerations

The fourth edition of DSM-IV includes notes on how culture can influence the expression of psychiatric disorders, although these are not included in the main text but rather relegated to the index and therefore marginalised. Richard Bentall (2003) points out that the DSM task force suggested that Anorexia nervosa should be described as a culture bound syndrome, but this suggestion was not taken up by DSM. Bentall points out that medical concepts are always embedded in a cultural system and indeed one could argue that DSM is itself culture bound.

The ICD 10, which is the International Psychiatric Nosology used in Italy, states that there is increasing evidence that anorexia is partly determined by socio-cultural factors. Concern and dissatisfaction about body shape and weight can be elicited by social pressure to conform and can be associated with feelings of inferiority, inadequacy and viewing oneself with contempt, the internal evaluation being something along the lines of “I am fat and a failure”

From the CAT perspective, human personality is determined by the interactions between individual variations and the beliefs and practices of the culture that one is born into.

CAT Formulation

Maria’s internalization of family values determined her relationships with others and herself.

Our hypothesis is that when Maria has looked for attunement, she has found only the problems and needs of her parents. Maria has adapted chameleon-like to this environment by being the thin, good girl. Thus her inner experience reflected the needs of others. There was no empathic environment for her emotional development, although she was the “perfect child” according to her perception of what her family required her to be: thin and top of her class. However, Maria has felt angry, needy, and lost. She has not had an environment wherein she could express herself. The eating dilemma is her solution to keeping abreast of her unmanageable feelings. She learned from an early age that relationships mean expectations to be fulfilled and not nurturance.

It is our opinion that Maria suffers from a disturbance of the self in which being admired by others for achievement and approval is central to her self-esteem. We propose that this is an understandable solution for Maria within the familial and cultural context in which she finds herself. She has found no mirroring but can be admired by being the top of the class and the very thin beautiful blond girl. She has strived to achieve the standard required by her family to make a woman attractive.

Maintaining Factors

Several maintaining factors appear to be present.

1) Her self-perception that her only choice is to get the better of others or they will get the better of her, “I win, you lose or I lose, you win”. Her double bind: she wants to be appreciated and liked but in trying to please everyone, she risks losing herself. Controlling her eating gives her the illusion of control of her life. First her family controlled her food intake now, now she does that herself.

2) The fact that her condition is medicalised: Maria is ill and must be treated in hospital, which is perceived by Maria as ‘They win, she loses’. ‘They are going to make me fat’.

3) Maria is bombarded by messages form her immediate family and from the surrounding culture that the shape of her body = her worth as a person. She was taught at an early age to focus on her weight. She has received positive reinforcement for being very thin.

4) In Maria’s perception, she has only two choices: she can be like her father and be fat or like her mother “who is dying of hunger”. There is no in between. She can please her father and be fat and be rejected by everyone or please herself and be thin and upset her father.

Therapeutic Intervention

Initial assessment

The therapist, during the course of five sessions, made the initial assessment wherein the Psychotherapy File, the PSQ, The Rorschach, and The Hamilton Depression Rating Scale were administered.

The Hamilton was again administered at the end of 20 sessions and at follow-up. The gains made at the end of the 20 sessions were maintained at follow-up.

Hamilton at initial assessment	BMI at initial assessment	PSQ at initial assessment
27	14	23

Method

• Introduction of the concepts of reciprocal roles and reciprocal role procedures

• The writing of a collaborative letter and SDR.

• Focusing on her self-to-self and self-to-other procedures

• Identifying her traps dilemmas and snags and collaboratively working on exits

• Helping her to reflect on her negative critical internalized voice and replacing it with a benign accepting voice.

Procedure

Maria was offered a time limited intervention of 20 sessions on a voluntary basis.

The Cognitive Analytic Component

Maria filled in the Italian PSQ. And the Italian Psychotherapy File (Fiorani & Poggioli 2000 translated with permission by A Ryle) ;

Traps-

• fear of hurting others

• trying to please

• low self esteem

Dilemmas

• Either I bottle up my feelings or I fear a total mess Choices about others-

• either stick up for myself and nobody likes me or give in and feel taken advantage of, angry, and hurt

• I feel that I am either a beast or a martyr (secretly blaming the other)

• With others either I am wrapped up in bliss or in combat

• If in combat I am either a bully or a victim

• When I am involved with someone whom I depend on then either I have to give in or they have to give in

• As a woman I have to do what others want or I stand up for my rights and get rejected.

Snags

• I fear the response of others.

A sequential diagrammatic reformulation was offered and described to her as a joint attempt at creating a map of her subjective self.( See diagram)

A reformulation letter was given to her at the 6th session, which contained target problems and an analysis of the transference.

The challenging of her negative internal voice and the replacement with a benign reflective internal voice to enabled her to be an advocate for herself.

We saw our roles as supervisor and therapist as being an advocate for ‘Maria the child’, who experienced the loss of herself through adaptation to the needs of her parents and the surrounding culture.

Maria was encouraged to develop the ‘observing eye’, whereby she stood back from herself and, together with the therapist, examined and thought about what she was actually doing in her inter-personal and intra-personal world. The consequences of her actions were considered.

She was helped to verbally express what she was feeling. In learning to do this and by referring to the SDR, Maria became more aware of how she struggled to keep in a position of being admired in her class. Although she more often than not succeeded, she felt no more than transitory satisfaction.

The school had a very competitive atmosphere and being the top of the class, and the beautiful slim girl also had its drawbacks. The other girls in the class were resentful and envied her. With the boys she felt she had to be seductive and desirable. The boys often viewed her as a trophy. She constantly compared herself to some unreachable standard.

With the help of the therapist Maria began to see that there was a middle ground between such extremes as success and failure and holding in all emotions or lashing out at others in an uncontrolled way. She became aware that in a relationship there were more possibilities than having to relate as if there were only two choices: to do things all her way or all their way. Maria was helped to consider such alternatives as mutual respect and interdependence.

With the weight gain she was helped to reach a position that might be satisfactory to her as well as to others, as her goal Maria decided to aim for the minimum weight needed to stay out of hospital.

Results

Maria decided to change school and now attends a less competitive school. She has started to develop relationships with girlfriends and has found that she has gained much support from this; she is also looking at boys as friends rather than potential boyfriends. Overall she feels under much less pressure and reports feeling more satisfied with her life. Her BMI has increased to 18 and has to date been maintained for a year. She states that she is better able to express what she is feeling within the family context.

Hamilton at one year follow up	BMI at one year follow up
20	18

Evaluation of Formulation

Maria’s was a complex case with several other professionals involved. In terms of the initial formulation, it appears to have been substantiated. The CAT component in particular appeared to have been successful. Maria and the therapist established a successful collaborative therapeutic alliance. The internal dialogue and reciprocal roles were challenged and new possibilities about how relationships can be are now being explored by Maria.

Maria had been bombarded by messages from her family and culture that the shape of her body was equal to her worth as a person. The issue of weight and how a woman looks is a constant conversation in the family and we feel that we have demonstrated that the family script helped in passing on a legacy of body shame, body dissatisfaction, and eating pathology to Maria. A mother’s dissatisfaction with her body has been found to predict eating disturbance (Davidson, Marcy & Birch 2000 quoted in Giles & Miles (2002) P.60).

Self-esteem is integral to the way that we define ourselves. Harvey et al (2004) argue that it is now evident that certain psychological disorders are specifi c to certain cultures or may appear and disappear as a function of changes within a culture. They quote a review commissioned by the BMA (British Medical Association) on eating disorders which pointed to their association with cultural values of weight and shape inherent in western culture.

Italian culture is one that encourages self-focus, “how am I perceived by others?” “La bella fi gura” is an important element of social relationships. In Italian culture there is a salient concern with body shape and weight reminiscent of the over concern with body shape and weight in eating disorders.

Ingram (1990), quoted in Harvey et al 2004, has proposed that self-focus attention is a problem across psychological disorders. Fairburn et al (2003) (quoted in Harvey et al (2004) have convincingly argued that the various eating disorders are maintained by such processes.

Maria’s reciprocal roles are understandable in the light of her familial context and also in relation to an expression of the experience of the surrounding cultural values. Her internal self-evaluation that if she is “fat” as perceived by the culture, she will then be regarded as a failure mirrors an imagined outer evaluation by others.

We have been looking at the psychosocial contribution to the formation of Maria’s personality. From the CAT perspective we have explored her internalization of reciprocal roles, which are her templates for the self-to-self and self-to-other ways of relating. Ryle’s starting point is neither the mother nor the infant, but that the infant internalizes those all-important aspects of the relationship between them.

Vygostsky stated that what a child does with an adult today she will go on to do on her own tomorrow. We feel that this has been clearly demonstrated in this case. Maria’s view of herself appears to have been infl uenced by her immediate and extended family as well as by the value place on thinness in a small provincial Northern Italian town.

References

R.P.Bentall “Madness Explained “ Psychosis and Human Nature. Penguin Books 2003.

Fairburn G, et al, (2003) “Cognitive Behaviour Therapy for eating disorders: a “transdiagnostic” theory and treatment”. Behavioural Research and Therapy 41, 509-28

Gilbert P. and Miles J. (2002) “Body Shame: Conceptualization, Research and Treatment” Brunner- Routledge.

Harvey A., Watkins E., Mansell W., Shafran Roz, (2004) “Cognitive behavioural processes across psychological disorders. A transdiagnostic approach to research and treatment” Oxford University Press.

Ingram, R.E. (1990). “Self-focused attention in clinical disorders: review and a conceptual model”. Psychological Bulletin, 109, 156-176

Miller A. (1981) “Prisoners of Childhood: the drama of the gifted child and the search for the true self ”. New York. Basic

Ryle, A. and Kerr, B.I. (2002) “Introducing Cognitive analytic Therapy: principles and practice”. John Wiley and Sons Ltd.

Cristina Fiorani is a Psicologo Psicoterapeuta and works for the AUSL (the Italian version of the NHS) treating girls with severe anorexia.

Marisa Poggioli is a Chartered Counselling Psychologist and CAT Practitioner. She trained in England and is developing CAT in Italy, she has a small private practice.

Full Reference

Cristina Fiorani and Marisa Poggioli, 2005. CAT and the Cultural Formation of a Case of Anorexia Nervosa: An Italian Case Study. Reformulation, Autumn, pp.13-17.

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