16-year old Mandy has anorexia nervosa. She and her 17-year old sister, Teresa, are on a walking holiday with their parents in Scotland. The scene takes place in the kitchen of their rented cottage, an hour after they had returned from an afternoon walking in the hills. The family are sitting round the kitchen table as mum prepares a light supper. The atmosphere is tense. Dad is sitting with his head in his hands. Teresa is glaring angrily at her sister as Mandy sits wringing her hands at the table. Mum flutters nervously over a large pot of soup on the stove.
WITHOUT MOTIVATIONAL INTERVIEWING
Teresa: Well folks, I can safely say this is the worst bloody holiday yet. The holiday to end ALL holidays.
Mum: Please darling, don’t make the situation any worse. We had a good afternoon – did you enjoy the afternoon, Mandy.
Mandy: Yeah, I guess so. The walk was nice.
Teresa: Nice? You say the walk was nice??? You spent the first couple of hours racing ahead of us. I thought the whole point of this break was to relax, take in a bit of the scenery, stop off at little pubs for lunch….well at least that was your story, Dad (swings round to glare at her father)…
Dad: It was … that was my intention
Teresa: ….so instead we spend the entire afternoon chasing after Usain Bolt here… then we get to the village where I’m STARVING and could kill some fish and chips, but hey guess what ? No can do. Anorexic Annie here decides no she will only eat soup for supper….so yeah fine, we all have to eat soup.
Dad: We said you could have fish and chips – do not start on that one. Don’t make the situation any worse Teresa
Mandy: I did not stop you having what you wanted Teresa. I just didn’t want any. I did not feel like that for supper. You can all eat what you want. I just didn’t want any of that type of stuff.
Teresa: And let’s not forget, it’s ALL about YOU…whether we’re at home, on holiday or on the bloody moon – life orbits around Amanda and her fads.
Mum: That’s not true Teresa
Teresa: It bloody is too.
Dad: Well tell us, what do you want to do tomorrow? Tomorrow we will do what you want to do
Teresa: Yeah, I’ve heard that one before…. OK I’ll tell you what I want to do. I want to get up, have a leisurely breakfast, go for a slow, leisurely walk in the morning, have some lunch and maybe catch a movie in the village in the afternoon ….then we ALL go for fish and chips for supper…you know…as a family….as a normal family would do on holiday….. Travel Advisor says it won best UK chippie 2010.
(Mum places a basket of bread then three large bowls of soup at their three place settings and a smaller bowl in front of Mandy)
Teresa: It’s like Goldilocks and the three bloody bears – for goodness sake give her a bowl the same size as the rest of us so we can get rid of this bloody illness, if that’s what it is……
Mandy: I’m not doing that.
Mum: Doing what, darling?
Mandy: Doing what Teresa, suggests we do tomorrow…… I’ll go for the walk but there’s no movies that I want to see and, you know, I just can’t eat anything from a ….chippie….
Dad: Yeah but we have got to cater for everybody, Mandy. It is a family holiday and we are all part of that family.
Mum: Maybe you and Teresa can go, and Mandy and I can come back here then – how about that?
Teresa: NO, NO, NO…she can stay here, how about that? Listen, I’m 17, this could quite possibly be my last holiday with you guys …has that ever crossed your mind this week???? Just for once, I would like to have dinner with BOTH my parents. I couldn’t give a damn about her...because know what? She couldn’t give a damn about me….in fact she couldn’t give a damn about…(sentence left unfinished, swallows back tears)….. She could not give a damn about me…. she could not give a damn about any of us…otherwise she’d eat a piece of bread.
Mandy: That is not TRUE. You know it’s not …
Teresa: Then prove it (slaps a large piece of bread in front of her sister. Prove it ! Eat that…
(Mandy tears a tiny piece of bread off and slowly puts it into her mouth with a disgusted look on her face)
Teresa: No, that is not big enough (tears a larger piece off). THAT’S a NORMAL bite size!
Mandy: I’m sorry…I can’t. (bursts into tears, gets up from the table and runs out of the kitchen)
Teresa: Dad, take me to the station tomorrow, I’m outta here. I have had enough!!!
WITH MOTIVATIONAL INTERVIEWING
Teresa: Well folks I can safely say this is the worst bloody holiday yet. The holiday to end ALL holidays.
Mum: I can see that you’re upset darling. This illness is hard on us all. Its whole intention is to drive a wedge in between our family. However, we will not let it do that to us. What are you thinking Mandy? Externalizing the illness, using a calm and compassionate approach + open question
Mandy: I spoil it all for you. I did enjoy my day mum, honestly and I am sorry, Teresa, if I’ve ruined it again. I did have a nice walk honestly….
Teresa: Nice? You say the walk was nice??? You spent the first couple of hours racing ahead of us. I thought the whole point of this break was to relax, take in a bit of the scenery, stop off at little pubs for lunch…well, at least that was your story, Dad
Dad: I know it’s tough for you right now and this break is intended to be as enjoyable for all of us as possible but… reflection using empathy
Teresa: ….so instead we spend the entire afternoon chasing after Usain Bolt here… I mean what was all that about, what were you trying to prove? That you can go faster and quicker than everybody else??? Sorry but I wasn’t aware that this holiday was about competition??
Dad: Ok, OK, OK, I can see what’s happening we’re beginning to be swept up on that emotional wave. Your mother’s right – we will NOT allow the eating disorder to destroy our family and our relationships with each other, right? So how about taking a deep breath, Teresa, calming down a bit and then we can talk about how we can do it better tomorrow. Complex reflection + externalizing the illness + encouraging calmness + suggesting a break (walking away from the emotional wave)
Teresa: …well for starters, I was STARVING and could have killed some fish and chips, but hey guess what? No can do. Anorexic Annie here decides ‘no’, she will only eat soup for supper….so yeah fine, we all have to eat soup.
Dad: Like I said, deep breath Teresa… We need to keep calm. How about eating this soup, first. None of us have to talk until we’ve finished, if we don’t feel like it. However, afterwards we’ll go over the mistakes that have been made today, the lessons learned and on a more positive note, how we work together to make tomorrow a more enjoyable day for all of us. Compassion and understanding + emphasizing individual autonomy
Mum and Dad sense the building pressure. They know their older daughter is upset over the day’s activities. They use empathy to take the heat out of the situation following this up by setting boundaries. Dad also rolls with continuing resistance, and offers some positive problem-solving strategies.
(the remainder of the meal is eaten in silence, Mandy glancing nervously at her family, eats the soup despite looking decidedly uncomfortable about doing so. At the end of the meal, Mum opens the conversation….)
Mum: So …we all seem a bit calmer. It seems like Dad and I didn’t get it quite right today which is OK. None of us are perfect. We didn’t realize that you were really in the mood for fish and chips, Teresa… However, at the same time…and this is where our anxiety plays a big part….we’re also very well aware that this dinner would have freaked the hell out of you, Mandy, and that your eating disorder would have screamed all sorts in your ear and the repercussions would have been that you wouldn’t have eaten anything. What I am wondering is whether either of you could come up with any possible solution …you know…if this was to
happen, say tomorrow? Lets’ start with you Mandy. Summarizes situation, using reflections, admitting mistakes that had been made, externalizing illness + emphasizing autonomy
Mandy: I could have sat in…but like I even hate the smell. I feel it seeping into my skin….
Teresa: Oh for goodness sake…
Dad: Thanks for that suggestion, Mandy. So we could have sat in but that would also make you uncomfortable, any other solutions?
Mum continues with the conversation at an appropriate moment. She uses reflections to summarize what she has picked up. She uses empathy toward Teresa and explains the rationale for their own actions. She then passes responsibility over to the girls exploring any better ideas that they may have that could better the situation were it to arise again. Dad chooses to lightly skip over Mandy’s irrational reasoning (smell of fat seeping into pores) refusing to engage in ED talk and instead gently probes further for her to come up with a more workable solution.
Mandy: Might we perhaps have brought it home – you guys could have had whatever you wanted and brought it back here…that way I could have put that fan on in the kitchen window and it would take the fat fumes straight out again.
Mum: OK, so bringing the food back sounds as if it could have been an option – what do you think, Teresa? Simple reflection + open question
Teresa: Not the perfect option as I wanted to eat in the chippie… but hey better than bloody soup.
Dad: …and hey few options in life are ever perfect kiddo….
Mum: This illness is tough on you both, on your relationship with each other. We WILL beat it though. You will once again share that lovely warm relationship you had when you were growing up. Teresa, I appreciate you letting us know when we’ve got it wrong and I think we’re so fortunate that we can talk openly and calmly about it in order to make it better next time around. Mandy, we will all continue to support you. You know we will never support your eating disorder. We want you back again and eating is non-negotiable. I’m going to wash up – how about if you girls go and discuss what you would like to do tomorrow, think of potential obstacles, Mandy, and how we can all jump those hurdles. Empathy + reminders of happier times + affirmations + boundaries + emphasizes continuing support, externalizing illness
Teresa: Mandy, I do realize how hard it must be for you. I find it really tough going at times to understand what you’re going through and I get so frustrated sometimes. Why don’t we try and do something fun after supper. Let’s have a game of Scrabble or something that Mum and Dad can also join in.
Mum uses humour to continue to try and take some of the sting out of the situation. She empathizes again with both her daughters reminding them of more positive times in the past. She affirms Teresa’s actions and thanks her for letting them know when they have made a mistake. This is an important role modeling lesson, i.e. that everybody gets it wrong at some point but that situations can be positively dealt with by using honest and open communication techniques. Again, mum uses consistent boundary setting to emphasize that eating is non-negotiable.