Intermediate Phase

In Session 3, the therapist checked in with Muriel regarding her week and used this opportunity to connect the occurrence of eating disorder symptoms with a troubling interpersonal situation. Once this connection was noted, the therapist worked with Muriel to keep the session focused on examining the interpersonal interaction and her feelings about that, rather than the specifics of the binge episode:

therapist: So, how did your week go in terms of the relationships with Peter or your mother, you know, like we talked about last time?

muriel: Yeah, well, not so good. My Mom called, and I was trying to get some things done, you know, while Gabe was at school, like, umm, while I still had some time and, well, she called all crying and stuff. All upset, you know? therapist: Yeah . . . mm-hmm.

muriel: Shed seen my Dad, and, well, umm . . . It’s just, I don’t know. I wanted to help, you know, but like I wanted to say, “Get over it already,” too . . . I just had so much to do and . . .

therapist: Did it create binge eating for you? muriel: I ate like a freakin’ pig. therapist: Oh [laughs].

muriel: I even had cookies in my purse when I went to wait for Gabe’s bus! therapist: Wow, wow.

muriel: [sighs] So, I think I’ve gained weight. I have to stop eating these cookies with—I make them with pudding mix. And the pudding mix is what gives you all the extra—my Dad like gained twenty pounds when I showed him how to make it . . .

therapist: Oh. Mm-hmm. So . . . although I wouldn’t wish that kind of situation with your mom on you, it sounds like it made a really—well, you really—made the connection between this interaction and all those emotions and the binge eating. And so, that’s really—the neat thing about that is that we don’t have to wait around and see if interactions with your mother and how you, you know, how you can let her know about what you need or about what you can really provide to her, how these things are going to be really important for us to work on . . .

muriel: Yeah, it’s really there, that connection.

By the sixth session, Muriel was regularly making connections between her episodes of binge eating and difficulties in her relationships with her family and husband. Although she was reporting fewer binge episodes, she was still experiencing at least one binge each week, and she still found it difficult to shift to a more equitable balance of giving and receiving caretaking in these relationships. While discussing a recent outing with her mother during which her mother had become faint, Muriel began to reveal concerns about her mother’s frail health and how these fears often made it difficult to turn to her mother for emotional support. Muriel felt that her mother had enough to worry about without hearing Muriel’s concerns. However, Muriel often binge ate after these “one-sided” outings during which all concerns were directed toward her mother. As Muriel explored this pattern with the therapist, she became extremely tearful discussing the months after her son’s birth when she was struggling with postpartum depression but did not receive support from her family. As illustrated below, the therapist encouraged the expression of feeling regarding her desire for support and her disappointment at not receiving it:

muriel: It horrified me so much that I was at that point of actually contemplating killing my child first, then myself. It was so selfish. [cries] I’m sorry, I’ve never told anybody.

therapist: I’m glad that you’re telling me. muriel: [continues to cry]

therapist: That’s a heavyburden to carry all byyourself.

muriel: Now people tell me they saw it. And now people tell me they were watching me but, like I told you, my family is all or nothing. therapist: Yeah, oh my gosh.

muriel: And they didn’t wanna—they saw me struggling and they saw me trying. I felt so alone. And I felt like I had to smile or try to make things better so that everybody else wouldn’t know how hard it was. Peter was already making me feel bad about that. [sighs]

therapist: In what way? How was he making you feel bad?

muriel: He made this comment to me one day, he told me that I had six months to get it together. Or things would change and he would leave. And I lost it, I mean I just—going through that depression with the baby and trying to make ends meet in a cramped apartment and baby stuff everywhere and you couldn’t really clean because it was shuffling stuff where I was cleaning up, and he had the nerve to stand there and tell me I had six months to get stuff together, when I couldn’t do any better. It wasn’t even a point of trying, I could barely put one foot in front of each other, and nobody was taking care of me. I couldn’t even take care of myself. There’s a part of me that’s still guilty right now because if I had—I just felt like if I had been a stronger person or if I—if there was some reserve, some place that I could have dug deeper in or I should have been able to see, or I should have been able to notice before that, even though I know that cerebral palsy isn’t my fault, there’s a part of me that says, “You should have been a better mother, you should have saw it,” or I could have prayed harder. [cries] therapist: Yeah, my gosh, that’s a really hard time to think about, you were so depressed and exhausted and trying so hard to make everyone think you had it all together, and instead of help you got watched or threats but no real, you know, help; and you kept thinking if only you could do better it wouldn’t be so hard, as if you were the one who was doing something wrong. . . muriel: Yeah [sighs]. That’s how I always feel.

therapist: Well, I can see how you would feel that way since, umm, your family seems to take a “wait and see” approach when they see someone struggling, you know, but that doesn’t necessarily mean you’re wrong if you need help and aren’t getting it. Since you’re so good at helping out without being asked, I would think that would make you feel kind of bad or make it hard to figure out “why do I need to ask for help and no one else needs to?” You know? muriel: Yeah, like I’m having to beg or something or with my husband, how could he not see me struggling? How could he speak to me that way? therapist: It sounds like you’re still having feelings about that, and, um, well, do you think, if you do have those feelings, how maybe that might make it hard to try to rely on him now, you know, after all that . . . What kind of feelings do you have now as you think back or, um, or what kind of feelings do you remember having then, you know when you “lost it?”. . .

In the weeks after the emotionally charged Session 6, Muriel was able to work more directly on both resolving disputes and improving her communication with her husband. With encouragement and coaching, she was able to talk with him about her concerns and to make direct requests for his help with their son’s care. As a result, the quality of their marriage improved considerably and her binge-eating episodes decreased.

therapist: So Peter has been trying, at your, uh, request, suggestion, encouragement, um, been trying to spend more time with Gabe? muriel: Trying.

therapist: And you even talked about the church with him, and kind of said, “Look, we’ve got these people who bring these really ill-behaved kids to church activities, why aren’t you bringing our son who has the potential actually to be well- behaved?"

muriel: Mm-hmm, yeah. Just we need to pay attention to him! We need to include him! That’s my biggest thing [. . .]

therapist: You’re talking to Peter now like, “Look, you’re the Dad.” You’re saying “We," like “What kind of family life are we giving Gabe?” You know? Like, “We need to do this as a family” Even though, sometimes, you know, you have to lead by example. muriel: Yeah.

therapist: Because Peter’s not nearly as adventurous as you are or feels as competent as you do with Gabe. And it sounds like mistakes just really freak Peter out [. . .] muriel: Yeah.

therapist: So it sounds like you’re doing a really nice job of, um, telling Peter what you want, talking to him as if he’s already on board or part of the team, and leading by example [. . .] And he’s working—I mean, he’s a slower, uh, burn, you know—but he’s working on it.

muriel: Yeah. It’s been going pretty, pretty good, cause I don’t just go into a rage, you know? Now I say, “No, I’m angry with you for doing that . . ” Just, some of the behaviors he does are just flat-out inappropriate or just nerve-wracking [. . .] therapist: Yeah, exactly, you can still be a team and still get angry [. . .] and that’s what it sounds like you’re working on: how to communicate being angry and communicate that you want Peter to do something different— muriel: And not turn in on myself and sucking it up and doing the exact opposite and binge eating. therapist: Yeah, right. muriel: ‘Cause I can’t do that anymore.

therapist: Right, you can’t do everything that you wish other people would do, and you can’t browbeat everyone into doing it. So that’s really—I think you’re doing a nice job of recognizing the dilemma that you find yourself in sometimes based on what your Dad taught you about that. But also realizing that you have all sorts of good people skills to find another way. And I think you’re doing that with Peter most times now, saying, “How are we gonna handle this? We’ve got a problem, our son needs X, Y and Z” Instead of telling Peter what he has to do or just doing it all by yourself and yelling at Peter that you’re having to do it all. So that “we- ness” is a big step of breaking out of that martyr or aggressor pattern that people can get into. muriel: Mm-hmm.

Buoyed by her success in improving her relationship with her husband through more direct expression of her needs and concerns, Muriel began to extend this pattern of interacting with other family members. For example, in Session 10, Muriel described a significant change in her pattern of responding to a request from her father to watch his child:

muriel: My Dad had called during that, um, nap, and I was half-asleep/half-awake, and he asked me can I watch his son, my little half-brother, who’s, um, a couple years younger than Gabe. But, um, I don’t know, I always had mixed feelings about that. My Daddy has this attitude like, “Well, we’re family," and we’re just supposed to pile together and get along like little puppies. therapist: Oh. Hmm. As if the circumstances don’t matter.

muriel: Yeah. And to a certain extent, it doesn’t because family is family. But don’t expect me to act like I grew up with this child. That we grew up in the same household. I’m in my thirties, I have a husband, my own marriage, my own child, our own problems [pause]. It would be different if I was seventeen, still living at home, and this was my mother’s child she had later in life. therapist: Mm-hmm. muriel: But it’s not. therapist: Exactly.

muriel: Just even with the babysitting. You know how we’ve just been talkin’ about, about defining those boundaries? therapist: Mm-hmm.

muriel: Not being afraid to say no, or quit sucking it up. And I found myself doin’ that [just sucking it up] when he was asking, he said, “Yeah, I need to drop him off around 3 o’clock Sunday.” therapist: Oh. As if you said “yes” already.

muriel: Yeah, and um, and I paused—there was a big—I remember a big pause in there after that and you know, I was about to say, just go ahead and say, “Yes.” And he said, “and I should be able to leave outta there around ten o’clock.” And I remember shooting up saying, “At night?!” therapist: So three to ten o’clock— muriel: [Simultaneously] Ten o’clock at night!

therapist: With a little guy, when you’ve got your own bedtime routines and stuff. muriel: Much less! And that pregnant pause there like it was an expectation. And then I had to get off the phone real fast cause Gabe needed me and I hadn’t said, “Yes,” but I hadn’t said, “No.” therapist: Mmm.

muriel: So I tried to call him back to tell him “no” and he didn’t answer so I drove by the new house, and he wasn’t there. therapist: Mmm.

muriel: So either he was gone or with one of his little lady friends or whatever, but um, I left a note on the door, a very simple note that you couldn’t take or blow out of proportion. It just said, “Daddy, I was half-asleep when you called, and I realize what a long stint of time this is. I can’t watch [child] for that long of a period.” But um, and I said, “[child] will just have to go back home with his mom,” and it said, “I’m sorry.”

therapist: Mm-hmm.

muriel: Point blank. If he wanted to get mad, you know, it wasn’t a negative or nasty tone, but —

therapist: Yeah, you weren’t saying, “How dare you!”— muriel: Yeah.

therapist: Yeah, good for you!

muriel: So I wrote him the note; he never called. So I called my aunt to tell her what happened and what I told my Dad in the note. When I first told her, she said, “You’re feeling guilty, quit worrying.” She said, “Quit hanging yourself up.” therapist: Oh, she did? Good!

muriel: She said, “Muriel, you gotta put your foot down” And I said, “Yeah, Auntie, I’m getting a little counseling about that [laughs] and some other things” therapist: Oh, I’m so glad that you talked to her about your worry, you know what I mean, and I’m guessing that helped you not binge over this on— muriel: Saturday. Yeah. I said, “Okay Muriel, you’re doing good!” therapist: Great!

In the latter sessions of the intermediate phase, Muriel also began to explore avenues for developing friendships. She joined a book club and began to more regularly attend the parent volunteer functions at her son’s school, and she and her husband joined a Bible study class at their church for couples.

 
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