Psychosomatics Families: Anorexia Nervosa in Context
, and Cambridge , Massachusetts , Harvard University Press , 1978 , 351 pp. $15 .
This volume provides, in my opinion, the most convincing and documented “manifest” by which a psychiatrist, together with his team, tries to persuade his colleagues that it is time to part from the individual model in order to understand and cure anorexic patients. I hope that this book, born of long years of unflagging work, will be an effective change agent in the world system of psychiatry. This will happen, I hope, despite the pessimistic reservations voiced by the authors themselves, who say: “Unfortunately, investigators of anorexia nervosa have demonstrated, to a startling degree, the blinders imposed on the scientist by his conceptual model. Practitioners maintain their previously learned paradigms as though they were causes to be defended, not hypotheses to be tested” (p.19).
The opening sentence of the first chapter hurls the reader right into the climax of a family session with the immediacy of a dramatic and well-timed film sequence. Thus the reader is led to negotiate the transition from the various theoretic perspectives on anorexia nervosa — the medical, psychodynamic, and behavioral to models — to the family systems perspective.
The chapter devoted to the anorexic family is suitably introduced by a more general, highly interesting chapter concerning the psychosomatic family. This illustrates the development, seen from the historical angle as well, of the creative cooperation, started many years ago by Minuchin, with the medical and nursing staff of the Clinical Research Center of the Children's Hospital of Philadelphia. This perfectly functioning collaboration confers to the research its perhaps unique character. The inquiry was concerned with psychosomatic families with asthmatic and diabetic children. The latter qualified as psychosomatic because, as opposed to “normal” diabetic children, they very often suffered from organically unaccountable acidosis crises that made it necessary for the child to be frequently hospitalized. It was exactly the observation of certain relational patterns, typical of these children's families, that led the research team to look at the critical role of the family in psychosomatic disease. The report of these researches contains extremely interesting data on the free fatty acids (FFA) in the blood of psychosomatic children during simulated stressful family sessions with two control groups, one with “normal” diabetic children and one with diabetic children having behavioral problems. These data, which include also the “turn on” and “turn off” phases connected with the emotional stress, are reported graphically and very clearly in Figure 3, pg. 47. (I draw the readers' attention to a printing mistake in the title of this chart: it reads “anorexic” instead of “diabetic” children.)
While this research was in progress, Minuchin and his colleagues outlined certain characteristics of overall family functioning that they labeled with the following terms: enmeshment, overprotectiveness, rigidity, lack of conflict resolution (and, last but not least, child's involvement in the parental conflict). The counterpoint to these relational characteristics is found in Chapter 5, where strategies applied for eliminating them are described. Among these, the widely famous Lunch Session is certain to give rise to the greatest interest, on account of its dramatically revealing impact. With inpatients, this session takes place in one of the hospital's rooms, after a rather short period of observation and estimate of the identified patient, including the patient's response to a behavioral program. The Lunch Session consists of the tactic of a meal partaken by the therapist and the anorexic child together with the family. This kind of session, which is meant to induce crisis in the family, at the same time allows the therapist to make basic observations. In the clinical section of the book in which the reader is introduced to four families, every single detail of the scene is reported through transcripts of the session tapes.
The clinical section dealing with casuistics is extreme]y useful for the purpose of showing the idiosyncratic, as well as other recurring features, that are so tediously common to all anorexic families. Furthermore, in this part of the book, one of the most successful attempts to introduce the reader to the therapist's style and technique has been realized. Chapter 7, headed “The Outcome.” supplies, with a number of tables, the clinical characteristics, the amount of time required for family therapy, the immediate results, and the follow-ups (from a minimum of eighteen months to a maximum of five years) recorded in connection with a great number of families treated: exactly 53. The total percentage of recoveries is very high, ranging up to 86 per cent.
Still, the reading of these tables has lead me to a reflection. They are in no way different, as to their format, from the charts that are being published and that I, too, have published, in 1963, as an estimate of individual treatments. The identified patient is their only subject. This shows how far away family therapists are from being able to classify or to quantify the results of their work in organismic terms and not only in terms of the identified patient's symptom. This observation allows me to add a few words about Minuchin's criticism of me because of my present theoretical position. I confess I feel just a little double-binded. When I was a psychoanalyst, Minuchin found that I was (and pour cause) too centered on the individual. Now that I work from a systems frame, he finds that I am going too far in my conversion: “The system model could carry the practitioner into rigidities that mirror the mistakes of linear therapists, denying the individual while enthroning the system” (p.91).
For one who adheres to a systems model it is clearly impossible to deny the individual while enthroning the system, as if dealing with two opposite things. In point of fact, it is merely a matter of change of level: from the individual level to the systems level. Indeed the system is not something opposing the individual but including him. Copernicus did not deny the earth when he included it in the solar system.
I believe that the crucial point, at present, must be looked at the other way around. None of us family therapists, neither myself nor Minuchin nor any of our colleagues who claim they work in a systems model, have yet succeeded in thinking along really organismic lines without contaminations and relapses into the linear model. To succeed is extremely difficult; it is contrary to our learning, to the conditioning of language that we are obviously compelled to use. There is still a long way to reach that ecology of mind, foretold by Gregory Bateson. That, in my opinion, is the correct path for the human sciences so that they may escape at last from the state of crisis and incongruity of models that as with conflicting Churches, shake their credibility at the roots.
