Laura: A case presentation

Hope and Eating Disorders Programs provide individualized treatment

Susan Romanelli, LCSW, PhD
Former Director of the Menninger Hope Adult Program
Michele Cook, MS, RD/LD
Dietitian, The Menninger Clinic

About Hope
The Menninger Clinic offers diverse treatments with psychodynamic, rehabilitative, cognitive-behavioral and other evidence-based vantages. On the Hope Program, psychiatric rehabilitation principles and techniques have been integrated with psychodynamic principles with significant emphasis being placed on a biopsychosocial treatment perspective. Concurrent examination of the source of symptoms and behaviors within each of these domains results in individualized treatment plans.

The Hope Program provides treatment to adults with a wide range of personal histories and diagnoses. Patients’ conditions are often considered recalcitrant, the patient may have had multiple inpatient and outpatient treatment experiences as well as multiple medication trials, without significant periods of success. Our patients commonly have come to identify themselves as their diagnosis, viewing all of their behaviors, emotions and thoughts as aspects of their pathology or diagnosis.

Hope patients’ diagnoses span the entire DSM-IV spectrum. Bipolar, major depression, schizophrenia, posttraumatic stress disorder, borderline personality disorder, narcissistic personality disorder, anxiety disorders and eating disorders are the most common diagnoses in the program. We also provide addictions counseling for chemical dependency or sexual, cutting or gambling behavior. There are no diagnostic exclusion criteria.

The following case example demonstrates how the treatment team integrated the psychodynamic, rehabilitation and biopsychosocial treatment perspectives and, because of a patient’s complex symptomatic profile, how we drew upon our colleagues’ expertise elsewhere in the hospital.

Presenting symptoms
Laura (not her real name) is a 30-year-old, never married, Caucasian female. At the time of admission to Hope, Laura stated that she had only come to Menninger to appease her family, and that she wanted to “keep suicide as an option.” Laura had made three lethal suicide attempts in the three months prior to this hospitalization, one of which was while hospitalized on an acute psychiatric unit.

Laura’s presentation is similar to many patients who come for treatment who are admitted to Hope. They feel hopeless and helpless, and are quick to dismiss any offerings of hope. They view themselves as a bag of chemicals and identify themselves as a diagnosis.

Laura was no different. At admission, she reported that she was a bipolar fraud. In fact, her diagnostic picture was much more complicated. Her admitting diagnoses were: Axis I: bipolar II disorder; severe, currently depressed (principal diagnosis); rule out posttraumatic stress disorder; pathological spending; rule out eating disorder not otherwise specified; rule out alcohol abuse; and Axis II: cluster B traits.

At admission, we consider each diagnosis and view the first two weeks as an assessment period. During this assessment period, team members gather information from the patient, family, significant others and referring clinicians, in conjunction with the staff’s observation of the patient’s symptoms and behaviors, especially in the milieu.

Personal and family history
Laura reported her mother had a normal pregnancy and birth. She was born and raised in a small Midwestern city, which her parents still call home. She met developmental milestones within normal limits. She reported that she always did well in school and was considered a child prodigy with her piano playing.

Laura said she had a very happy childhood, having many friends and boyfriends. She denied any sexual or physical abuse prior to age 20 when she was date raped. However, as treatment progressed, she did admit to being propositioned and fondled by her female piano teacher at age 9. She said she told her mother, who downplayed the event.

She reported a very close relationship with both parents, and a very conflictual relationship with her younger brother.

From as far back as she could remember, Laura said she wanted to get out of her home state. She gained a college scholarship to a prestigious ivy-league school. Significantly, she had to obtain a scholarship since her parents hadn’t saved for college for either child.

She reported that she did well until her sophomore year, when she had her first depressive episode. She sought out psychiatric care because her aunt and two cousins were diagnosed with bipolar disorder, so she was aware of the symptoms and need for medications. She began taking medications and was able to graduate with a 3.8 grade point average.

From age 21 to 28, Laura held high-level jobs at several advertising firms in New York and Baltimore. She made a six-figure salary from the beginning, which enabled her to her lead the lifestyle that she had always dreamed of when growing up: buying only the most expensive and fashionable clothes, dining at the finest restaurants and buying only antiques.

At age 28, however, the depression returned in full swing after her fiancé broke off their engagement. She reported that she also began drinking seriously at that time and she increased her spending, leading to her current $75,000 credit card debt and facing foreclosure on her $350,000 house. As her depression exacerbated, Laura had returned to her childhood home to be closer to her parents and had been on disability for the past year.

Initial assessment period
Laura presented as acutely depressed. For the first two weeks, Laura did not get out of bed except to take her medications. She reported unrelenting feelings of hopelessness and helplessness and thoughts about suicide. During these two weeks, she attempted to hang herself from the showerhead and to cut herself with a broken CD disc on her upper thigh and shoulder. She was put on suicide awareness status until she was able to contract for safety. She also wasn’t eating meals, and only drank coffee and soda. Initially, we believed that this was only a depressive symptom, but wondered if she had an eating disorder as well. We became concerned when her weight continued to drop. She finally admitted that she was trying to kill herself by starving to death.

Eating disorder and nutritional assessments were ordered from Michele Cook, dietitian for the Menninger Eating Disorders Program. Laura denied having an eating disorder, but Michele concluded that Laura had a very distorted body image and that she met criteria for eating disorder not otherwise specified. Laura reported that she had lost over 25 pounds in the past six months. Although she denied a history of restricting or purging, she did like her newfound thinness. She weighed 123 pounds with a BMI of 18.5 (A BMI of 20-25 is considered healthy for her height, which equals 131 to 164 pounds).

Michele recommended that Laura begin eating her meals on the Eating Disorders Program, but she refused. Instead, Laura continued restricting her food and rejected going to the cafeteria. When the patient’s weight continued to drop, Michele recommended that Laura transfer to the Eating Disorders Program because we couldn’t properly treat her depression if she wasn’t eating. It quickly became apparent to the Hope treatment team that Laura’s symptoms were so intertwined that she needed to address her eating disorder before she could address her other issues. If she chose not to transfer, we informed Laura that we would transfer her to the acute psychiatric unit at The Methodist Hospital since we believed she was putting her life at risk. She finally agreed to the transfer to the Eating Disorders Program with the stipulation that she could participate in some Hope groups, specifically group psychotherapy and the family issues group.

Eating Disorders Program
Transfer to the Eating Disorders Program was pivotal to Laura’s treatment. The Eating Disorders Program uses evidence-based protocols. Initially, patients are required to eat meals on the unit and sit for 45 minutes under staff observation. Patient bathrooms are locked. The dietitian prepares the menu; if a patient doesn’t eat all of the meal, he/she must drink a liquid supplement. Laura was typical of many Eating Disorders Program patients. Resistant at first, Laura began to eat her prepared meals and benefit from the program’s groups, particularly on food and feelings and body image. In food and feelings, Laura wrote in a journal her feelings after a chocolate exposure. Laura was very sarcastic about this exposure, but was finally able to admit that she often uses sarcasm to hide her real feelings.

Laura returned to Hope after two weeks, but continued to eat her meals on the Eating Disorders Program, attend selected groups and go on the program’s lunch outings, which are considered exposure therapy. Michele continued to meet with Laura weekly in order to monitor her weight and her diet.

Return to Hope: Psychodynamic & rehabilitation treatment
Upon return to Hope, the team placed Laura into groups that addressed both her psychiatric and addictive symptoms. By using the rehabilitation model, we help patients understand their strength and weaknesses, as well as help them to begin to have self-agency, which is often destroyed by psychiatric symptoms. The group structure provides an opportunity for patients to share their histories and emotions, as well as an opportunity to share solutions. Laura participated in group psychotherapy, family issues, trauma psychoeducation, women’s group, dialectical behavioral skills training, grief issues, overcoming depression/anxiety, overcoming perfectionism, anger/stress management, relapse prevention, weekend review/addiction recovery, 12-step recovery, relapse prevention/addiction, dual diagnosis and cognitive behavioral treatment. She was also assigned a therapist with whom she had twice-weekly psychotherapy sessions.

Laura had an addiction assessment by Michael Rios, an addictions counselor from the Adolescent Disorders Program who specializes in self-injurious behaviors. After assessing Laura, he believed her cutting had become an addiction; whenever she became overwhelmed with intense feelings, she would cut to seek relief and diversion. He also believed her spending had an addictive quality and she would benefit from attending addiction groups. Laura met weekly with Michael throughout her hospitalization.

When Laura was first admitted, she had multiple diagnoses. Due to the severity of her depression and suicidality, her rapid cycling throughout the six months prior to admission and her family history of affective disorders, the principal diagnosis given was bipolar II disorder. However as her depression lifted, it became apparent to the team that the constellation of symptoms and behaviors lay more in the diagnostic spectrum for borderline personality disorder, which explained the intensity of staff responses to Laura’s return to Hope.

Recent research has noted a strong comorbidity between borderline personality disorder, bipolar disorder and eating disorders. Individuals with borderline personality disorder often exhibit similar affective instability, depression and unrelenting suicidal ideation as persons with bipolar do, while they share a prominent history of sexual abuse and poor self-image with many persons experiencing eating disorders. Research has suggested individuals with borderline personality disorder often use the pursuit of thinness to enhance their low self-esteem. Binge eating may be one of their self-soothing mechanisms, and restricting food may also give them a sense of control in an otherwise chaotic world.

Laura was able to discuss her difficulty with interpersonal relationships and the need to show the world a false facade, but she wasn’t able to discuss her feelings of emptiness or need for a false facade. Two pivotal events shook her resistance.

Midway through her hospitalization, Laura’s abandonment fears exacerbated when a patient, with whom she had become friendly, discharged. She became acutely suicidal and was placed on suicidal awareness. She requested discharge, signing the formal letter. Because she was on suicide awareness, discharge wasn’t an option. We offered our interpretation of the discharge request. Laura was dismissive, stating that this interpretation was staff’s narcissism and omnipotence, not her abandonment issues.

In the second event, the patient manipulated her primary clinician into changing a team decision. When the primary clinician reflected to Laura about her feelings of manipulation, Laura denied this was her intent. Not surprisingly, she had great difficulty accepting that her primary clinician could hold her in a positive light if she felt manipulated, thus showing the classic borderline difficulty with holding both the good and bad object. Laura also could not hold these two contradictory opinions inside herself.

Both events happened about three days apart. She then opened up in all treatment modalities: group, individual and clinical rounds. With increased access to her feelings, she began to mentalize. She was able to discuss her feelings of emptiness, of being a fraud, the need for a facade and fears of abandonment, and she came to a better understanding how these feelings fueled her depression and suicidal ideation. Psychological testing also confirmed our clinical observance “out of these characterological patterns arise a major depression marked by pervasive apprehensiveness, anhedonia, self-blame, self-dislike and feelings of worthlessness.”

Her family sessions became richer with this newfound awareness of her emotions. Laura had weekly family sessions with her parents and her primary clinician. While she had feelings of guilt about not being a good daughter, she began to recognize the etiology in her family structure. For example, she was looked at as the “wonder child,” who needed to succeed to mask failures in the family. Although painful at times, Laura began to recognize that she was trying to fulfill her parents’ view and expectation of her, such as having a high paying job despite that it didn’t make her happy and buying an expensive house and car despite that it put her into serious debt and contributed to her feelings of being a fraud. She recognized her parents were more interested in appearances to the world, rather than truly understanding her and her brother. Laura attempted to inform her parents of her feelings of being empty inside and a fraud, but to no avail.

Countertransference
Laura’s developmental and family history helped explain the etiology of her symptoms and behaviors, but her dynamics in the milieu provided the most fruitful data. She produced strong countertransference in all staff members. No staff member was neutral about Laura. Rather than suppress such splits, staff members were encouraged to examine their countertransference as a way to understand the patient. The team believed all of Laura’s symptoms and behaviors have underlying meaning, and that she reenacted past relationships with different staff members. From a psychodynamic perspective, we expected that Laura would show us her internal world through these interactions, which were reenacted in the milieu.

In order to deal with splits and strong countertransference, the treatment team routinely meets twice weekly to discuss each patient. All team members are encouraged to attend these team meetings: psychiatrist, primary clinicians, nurses, mental health counselors, rehabilitation counselor, chemical dependency counselor and utilization review coordinator. In these meetings, we openly disagree, point out patterns and come to some decisions that will guide each patient’s treatment. This open discussion and dialogue leads to a better understanding of the patient and us.

In the meeting about Laura, both the primary clinician and individual therapist acknowledged it felt good to be the good objects. Both understood the patient had intense identification with them, and Laura was very cautious not to devalue them due to her fear they would abandon her. The psychiatrist and rehabilitation counselor were more neutral despite thinking that she was engaged in treatment. The nursing staff, on the other hand, believed Laura was manipulative and that her core team was blind. In conjunction with her opening up in groups, we were able to understand our different countertransferences and what they represented about Laura’s internal world. We used this information with Laura. By sharing the meaning of our countertransferences, Laura began to mentalize and expose her internal world to others with new braveness and a feeling of hope.

Summary
As Laura was able to reflect on the relationships with the staff, she began to open up in groups about her fear of being discovered as a fraud and her overall sense of internal emptiness. She was able to reflect that her sarcasm was her way of keeping people at a distance, and she was sure and fearful that nursing staff would be the first to detect it. She understood that nursing staff members often see patients when their guard is down, interacting with patients in the milieu especially during the evenings. She also began to understand her own internal state that led to her deepest fears, which she could now tolerate. She went from a bag of chemicals (we actually reduced her medications from 10 to two) to feeling human, with a renewed sense of hope based on growing accessibility to her internal world.

Laura benefited from the integrated psychodynamic and rehabilitation treatment model.
Clinician countertransference is key to the treatment of the complex patient.
Diagnosis is only one tool in the assessment process.

Postscript
In a Christmas card to the Hope team, Laura wrote that she was doing well, but still struggling. She denied any hospitalizations since discharge.