Interpersonal Problem Formulation

To highlight the connection between certain life experiences, the quality of interpersonal relationships at those times, and eating disorder symptoms, the therapist asked Muriel to recount both her earliest and most recent episodes of binge eating. As noted above, the first episode of binge eating that Muriel could recall occurred when she was on bedrest during her pregnancy and her family did not respond with the type of caretaking that she thought they should given her medical condition; and most recently after she had spent the day taking her mother (who had never learned to drive) to her doctor’s appointment, picking up her mother’s prescription medications, and doing her mother’s laundry while Gabe was in school. Muriel described how she went back home following this time with her mother and binged while waiting for the school bus to arrive. When asked to describe the emotions she was having prior to this most recent binge, Muriel noted that she felt overwhelmed by her role as her mother’s caretaker and she resented that other family members did not see that she had more than enough to take care of herself and did not offer to pitch in and help out with Muriel’s mother.

The therapist then began to fill in other events from Muriel’s life, linking each increase in eating disorder symptoms with changes in mood and major disruptions in the roles she assumed or were expected to assume in her interpersonal relationships (see Table 8.2 for a chronological history of significant life events, mood fluctuations, relationships, and problems with eating and weight).

Table 8.2. Life Chart Chronological History

Table 8.2. (continued)

By the end of Session 1, the therapist and Muriel agreed that there was a strong interpersonal link between her binge eating and mood disturbances. The therapist proposed the following problem formulation (interpersonal disputes) for Muriel to consider: (1) Muriel’s mother and husband Peter expected Muriel to be the primary caretaker in their relationships, which made her feel overwhelmed and resentful, particularly when the caretaking was unreciprocated; and (2) she had difficulty appropriately recognizing and expressing emotions, especially anger, in intimate relationships, making it difficult for her to resolve disputes with significant others. Muriel agreed that these problems in interpersonal functioning were contributing to her current disturbed eating patterns and depressed mood and that these would be appropriate areas upon which to focus treatment. The therapist agreed to put this formulation and goals for treatment in writing (Fig. 8.2) for their review and discussion at the next session.

Excerpts from transcripts of this second session illustrate the presentation of the treatment goals to Muriel in a collaborative manner. The therapist works to elicit Muriel’s agreement with the salience of the proposed problem area, and her commitment to working on the treatment goals for the remainder of the sessions. Although presenting problem areas and therapy goals in a collaborative manner is a hallmark

Problem Area #1 (Interpersonal Disputes):

During our meetings you have described how you binge eat when you and your husband or other family members disagree regarding how best to deal with a situation and/or when you do not feel quite up to the task being asked of you, or when you feel forced or obligated to deal with a situation that you do not want to deal with. You are likely to binge eat when you feel uncomfortable with the conflict or the anticipation of the conflict that might result if you choose not to deal with a situation in the way you think is expected of you.

Also, during our meetings you have described how you are the emotionally “sensitive” member of your family. This sensitivity has been a great gift in that it causes you to be an empathic and caring family member and friend. However, it often causes you to feel responsible for carrying the emotional “burdens” of family. Since you may be the first to recognize distress or conflict in a relationship you may feel the need to intervene or diffuse the situation, even if it means putting your own needs and feelings on the back burner in a particular situation. This pattern of tuning into others rather than into yourself can cause you to become disconnected from what is going on for you emotionally. You may find yourself feeling drained or inadequate or lashing out in anger without warning. These feelings can cause you to want to withdraw from others just when you could use social support the most. Over time you have learned to rely on binge eating rather than on other people in an attempt to soothe or satisfy your longings and emotional ups and downs.

Goal #1:

When you start to binge-eat, pause to think about your own emotions or hunger level and think about the situation you are trying to adjust to or deal with. Remind yourself that binge eating may provide some respite from problems or feelings of inadequacy or conflict in the short run, but in the long run it diverts energy from acknowledging the difficult situations confronting you and from taking actions or making plans to change the situation. As you return your attention to the situation at hand you will be able to acknowledge your own wants and needs during these challenging interactions. In this way you will be able to make plans or begin to implement changes that are necessary to manage the situation or dispute and not get sidetracked by the negative feelings that arise from binge eating.

Goal #2:

During our work together you will be able to stop this cycle of binge eating by stepping back and noticing when you are feeling lonely, angry, frustrated, bored, or sad for yourself versus having these feelings for others. You will be able to make conscious choices to deal with these feelings and situations in ways other than with food. As you find ways to receive emotional support from others to balance your skill at providing such support you will rely on binge eating less and on your social network more.

Figure 8.2 Problem formulation and treatment goals

of IPT, this stance is particularly important given Muriel’s pattern of accepting other people’s requests with unspoken resentment:

therapist: As we discussed last time, I’ve written up a couple of goals— muriel: Okay.

therapist: I think maybe based on what we talked about in our last visit, they seem like they might be in the ballpark. And so I wanted us to look at those together today.

muriel: Okay.

therapist: A couple of warnings: sometimes because they’re so nicely typed— muriel: Mm-hmm.

therapist: —people feel like they have to go, “Oh, okay" when they see them, but that’s not the plan. The reason they’re typed is so we can really think through the goals together and make them what you want to work on. So you’re going to read them a couple of ways: one is, you’re going to read this piece of paper as something we definitely can change . . . muriel: Okay.

therapist: Two is, you’re going to read it in terms of, does this really summarize what we’ve talked about and what we’ve come to learn about the connection between your binge eating, your emotions, and your relationships, okay? muriel: Okay.

therapist: And three, would you benefit from working on these goals? Okay, so let me give you something to set this on so that if you want to make notes, you can.

[Patient and therapist read silently for a minute] muriel: Yep, you hit everything on the—right on the head. therapist: In what way?

muriel: Just like #2—the uh, “lashing out in anger without warning"— therapist: Mm-hmm.

muriel: It’s a constant with my husband. I’m so angry with Peter. I’m just constantly— even when I tell myself, “Okay, just—calm and relax and smile” or, you know, try not to take everything he says so personal, it always—to me, it is personal. therapist: So the more you try to kinda ignore it, the more it bubbles up out into anger?

muriel: Yeah, it’s like whatever I have to do is inconsequential or not worth a second thought, and, like last week was one of those times when I really could have— I never really ask Peter to watch Gabe . . . this was one of those times when I really could have used his help, because I really wanted to see everybody [at a social event for volunteers at her son’s school], to be around people, you know, for the friendship of it, but I didn’t want to eat around them so I didn’t ask him; but as the night went on, I felt more negative about the situation than I felt positive, and—and I just sat there feeling angry at him, and lonely, and eating anyway [laughs].

therapist: Yeah, so that’s a great example of how the second treatment goal emerged, and if we work on this goal, you think that might be helpful? Working on this goal would mean letting Peter know that you were nervous about going but still wanted to go and that you were annoyed that he didn’t offer to watch Gabe. Working on this goal would mean reaching out to Peter for help with these kinds of situations. Working on this goal would help you recognize that when you need people most for a social outlet is when you often want to withdraw from them because you are worried about your eating or about something else that might not be quite right. But by working on this goal you would kinda flip that over: instead of withdrawing and binge eating, you might take the risk, ask your husband for help so that you could be with people—because it sounds like you wound up thinking, if you had gone you would have had a nice time. And then that resentment wouldn’t build up towards your husband, and then you certainly wouldn’t have been lonely and angry and binge eating. muriel: Yeah, he doesn’t even know I’m coming to see you, I have to tell him . . .

therapist: I think one of the things in both of these goals is turning more toward checking in with yourself, paying attention to your feelings, and then, when possible, um, turning toward people rather than food for help or for support. So it sounds like when you look at these, the first person who comes to mind is Peter, with whom you would want to practice these goals, right? But it seems like such a negative interaction pattern has gotten going with him that it feels pretty hard to be optimistic about doing that.

muriel: Yeah, I’m just thinking, who can I talk to? I could talk to my Mom, but, I don’t know; there’s just that hesitance there of knowing that it makes her feel bad too, sometimes, that I feel bad. I don’t want to be an emotional dump for her. Even though the couple times that I have just broken down and talked to her, she’s asked me how come I haven’t talked to her before, you know, she always listens. But there’s still a part of me that’s still mindful that she has a lot of load to carry, and she’s barely making it, and I ask myself, “Why are you dumping your crap on her?”

therapist: We definitely need to work on increasing your circle of social support, but it sounds like you certainly could make more use of your Mom and of Peter, so there are two paths to increasing your circle of support: finding ways to more effectively use your husband and mother as social support people, and increasing the circle of people you can turn to for support. Now, working on [interpersonal] disputes in your relationship with Peter is going to be tough, because there are a lot of patterns that have gotten established. But the payoff is real big, because he’s your husband and someone you love a whole lot even though you hate how he acts a lot of the time. So, looking at these goals, do you think you want to work on these even if they would be hard? muriel: Yeah, these definitely do hit the nail right on the head. therapist: Do you think? muriel: Yeah. Theyreallyare [imperceptible]. therapist: In what way are you thinking?

muriel: Just like I said, the overwhelming parts of my life that I’ve been feeling all week, both of these just flat-out sum them up. therapist: So what I’ll ask you to do is to, um, read these every day and be working on them, and then when we get together from now on, I’ll ask you how your eating has been and how working on these goals has been. And we’ll hopefully see things improving for your eating as things improve with these important people. . .