Posted by Dave: I have a long interest in patterns of illness in families. Much of my clinical work is involved in working with families referred by a physician where a member has an ambiguous chronic illness. An ambiguous illness is one where there are symptoms and disability but there is no definitive physical or laboratory evidence of disorder. Early in my life in Psychiatry I discovered that including the whole family is extremely helpful in illnesses of this sort. The situations that lead to and perpetuate illness are complex. I have learned there are no templates that lead to understanding or to healing, rather therapy requires attention, caring, tolerance for ambiguity, which in my case turned into a thirst for ambiguity. In the case that follows it seems that part of being a woman includes “not feeling well”.
The Case: The Swensons were referred by their family doctor. The main concern revolved around the oldest daughter, 17 year old Kim. She had had surgical repair of her scoliosis 16 months prior to the first interview. Eleven 
months after surgery the ‘halo’ appliance was removed and she started getting used to life unencumbered. But within two weeks she was diagnosed with infectious mononucleosis and was ill for eight weeks. While the serum findings faded out, suggesting recovery, her energy did not return. She had been an active athlete and a good student prior to the surgery. She was having a hard time finding her way back into the world and into her body. She was an apprehensive version of her pre-surgical self. Her difficulty returning to school, and life, prompted the family to call me.
Mother, Norma, and Father, Fred, were in their late 40’s and there were two more daughters, ages 14 and 11. They were what we think of as a conventionally normal family. There were no out of the ordinary stresses. Fred was the most emotionally dynamic parent, a lively, nice man who was considering a career change, looking for a better job. Norma was a bit more subdued, but involved with and thoughtful about her kids.
I saw them weekly, they talked about Kim’s experience of surgery and how she thought about her return to school. They talked about life events, how they were attempting to encourage Kim, how Kim responded. Sometimes, even when helpful, family therapy is not exciting. At the third interview they described a weekend family adventure, a trip to Fred’s sister’s lake cabin. Norma stayed home at the last minute because she was not feeling well. She didn’t say what the problem was. I hadn’t heard about a health problem and thought maybe menstrual cramps, or perhaps she had some unease with his family. There were no details. She “just didn’t feel well”.
Father and daughters had a wonderful time. Kim went for a swim and even did some diving the first time in over 18 months. Then the mother Norma didn’t come to the fifth interview because she wasn’t “feeling well”. I tried to better understand what her illness might be. “She’s just kind of under the weather some times,” said Father. As we went along I heard that Norma’s mother had health problems. Norma was troubled by her own mother’s health problems which had disrupted many family events. This had gone on all of her life. She had never been in good health. Like Norma she missed some family events because of her poor health. But also like Norma, there was no diagnosis. She was treated with a variety of medications. But I could get no clues as to what her illness was. Norma was surprised when I suggested she was following in her mother’s pattern.
Kim was getting better, feeling more confident. She and Dad and her 14-year-old sister shot some baskets the day before the interview. That was a giant step forward.
Short digression: I have lived and practiced in several different cities. I was working with the Swensons while in practice with the Family Therapy Institute in St. Paul, Minnesota where I had grown up. At the end of the 10th session as the family was leaving, Mrs. Swenson surprised me with a question. “Is Betty Keith your mother?”
“Yes, do you know her?”
She nodded, smiling warmly. “You used to be our baby sitter.”
I was amazed and puzzled. She told me a bit about her family and where they lived. I remembered babysitting in her house when I was 12 and 13. They lived in one of the larger new homes 2 blocks from our decidedly middle class neighborhood. Her mother was a trim, attractive, blonde. Her mother and father appeared energetic and appealing. The point is that Norma’s mother did not seem to be a woman who was given to poor health. So the characterization of her in the present was surprising.
I had developed the idea that Kim was caught in a family pattern where part of being a woman meant having an illness. Could it be that part of the problem was her identification with her mother and grandmother? I know it sounds a bit far-fetched, but this is how I think. I take the uncertain symbolic strata of the family into consideration. Identification is part of loving, especially part of the child’s attachment to a parent. Children in families are inevitably affected by the emotional atmosphere of their family.
My impression here is that Kim’s slow recovery was complicated by something to do with how to be a woman in this family. She went through a major surgical procedure, which probably disrupted her relationship to her body. It was as though being a woman meant having an ill-defined ‘health problem’ without diagnosis, it meant “not feeling well” when uncertain.
This unconscious mindset caused me to think the women in this family had an uncertain or ambiguous relationship to their bodies. Pediatrician/psychoanalyst Donald Winnicott suggested it is not a given that the soul shall reside in the body. The implication is that experience can disrupt the relationship between body and soul. Therapeutic experience can restore it. Kim recovered from what was troubling and she returned to school. Anxiety in the family went down and they soon ended their therapy work with me.
I was concerned they were leaving too soon. I proposed we have a few more sessions to include Norma’s mother, but they didn’t think it possible for the grandmother to come to my office. To be honest I don’t know what I did except to attend to them, to parent them which involved caring, empathy and attention. I wish I knew what happened next, but I don’t. I don’t know if the therapy had any effect on Norma.