The Rituals of Anorexia Nervosa

In systems theory, the family is treated as a whole that cannot be reduced to the sum of the characteristics of its members. What characterizes the family as a system is rather the specific transactional patterns it reflects.

Every family, considered as a transactional system, tends to repeat these patterns with a high frequency and consequently gives rise to redundancies. The latter enable the observer to deduce the rules, often secret and generally implicit, governing the functioning of a given family at a given moment and helping to maintain its stability.

If we define the family as a self-governing system based on rules established through a series of trials and errors, then its members become so many elements of a circuit in which no one element can be in unilateral control over the rest. In other words, if the behavior of any one family member exerts an undue influence on the behavior of others, it would be an epistemological error to maintain that his behavior is the cause of theirs; rather must we say that his behavior is the effect of past interaction patterns. The study of this type of family transaction is therefore the study of fixed behavioral responses and of their repercussions.

We have spoken of an epistemological error; the latter results from the arbitrary separation of a given behavioral pattern from the pragmatic context of the preceding patterns with which it forms an infinite series.

When I speak of "epistemology" I am not referring to an esoteric discipline reserved for professional philosophers. Every one of us, by his very being in a world he has to share with others, is bound to take a stand vis-à-vis his particular mode of existence, and hence to adopt a certain epistemology.

Again, when I speak of epistemological errors or bad faith, I am referring explicitly to a common error of modern Western culture (and hence of psychiatry): the idea that there is a "self" capable of transcending the system of relationships of which it forms a part, and hence of being in unilateral control of the system.

It follows that even such behavior patterns as reduce the ostensible victim to impotence are not so much stimuli as responses. In other words both partners in the transaction are mistaken --- the manipulator who believes in his omnipotence no less than his apparently powerless victim.

But if both are mistaken, where does the real power lie? It lies in the rules of the game played in the pragmatic context of the behavioral responses of all the protagonists, none of whom is capable of changing the rules from the inside.

By defining the patient as a pseudo-victim, we are avoiding the blind alley of moralistic psychiatry. It would appear that R. D. Laing and his school, precisely because they have adopted Sartre's distinction between praxis and process, have fallen into just this moralistic trap. By contrast, if we treat the family as a system in which no one member can hold unilateral sway over the rest, then praxis and process become synonymous. "Persecutor" and "victim" become so many moves in one and the same game, the rules of which neither one can alter from within --- all changes depend on strategic interventions from without.

In the particular case of a family with an anorexic patient, we find that the epistemological error of the whole group is that all of them believe that the patient, because of her symptom, wields power over the rest and renders them helpless. If we were to take a snapshot during the very first therapeutic session, we should see an anguished expression on the parents' faces, the patient sitting apart from the rest, straight as a statue, pallid and detached, her face showing utter indifference to the others' distress. Her behavior is a clear message, not least to the therapist:

If you think you can get me to break my fast, you'll have to think again. Just look at me: I am nothing but skin and bones and I might easily die. And if death is the price I have to pay for my power, then I shall willingly pay it.

This shows that the patient completely misjudges her own situation. To begin with, she is prey to a most disastrous Cartesian dichotomy: she believes that her mind transcends her body and that it grants her unlimited power over her own behavior and that of others. The result is a reification of the "self" and the mistaken belief that the patient is engaged in a victorious battle on two fronts, namely against: (1) her body and (2) the family system.

Now this error could not be called a mental illness, were the patient to adopt it voluntarily and were she to declare quite openly that she will take no food until she gets what she wants. This would constitute a rational choice on her part, not a "mental condition." Instead the anorexic sticks rigidly to the family rule that no one member may assume leadership in his own name. That is precisely why she derives her powers from an abstraction: her illness. It is the latter that wields power, afflicts her own body and makes others suffer for it. Like every mental symptom, the anorexic symptom, too, is a paradox oscillating between two illusory poles: spontaneity and coercion.

This raises the following problem: does the symptom indicate that the patient does not want to eat (spontaneity) or does it rather show that she cannot (coercion)? If we take the epistemological view we have just adumbrated, then we must answer both questions in the affirmative. The anorexic herself, however, insists that only the second alternative is correct, that is that she really cannot eat.

In dealing with such patients, the psychotherapist must therefore pay careful heed to:

the false epistemology shared by all the family members, that the patient is in unilateral control of the whole system;
the patient's belief that her self (or mind) transcends her body and the system, and that she can wage a successful battle on two fronts;
the fact that this battle is never waged in the first person, but in the name of an abstraction: the disease for which the patient cannot be held responsible; and
the fact that this abstraction is considered "evil" because it inflicts suffering on all concerned.

The therapist must devise his strategies accordingly and, in particular, he must aim at correcting the false epistemology underlying all these phenomena. But how is he to do that? By academic discussions, by communicating his insights, or by critical remarks? If he takes any of these courses, he will, as we have found to our cost, be sent away with a flea in his ear. What he must rather do is, first of all, reduce all members of the system to the same level, that is assign them symmetrical places in the system. Having observed the prevailing communication patterns, and avoiding the temptation of participating in any of the mutual recriminations, he will make it a point, and one that never fails, to approve unreservedly of all transactional behavior patterns he observes. We refer to this type of intervention as positive connotation, and the therapist must extend it to even those forms of behavior that traditional psychiatry of psychoanalysis pillories as destructive or harmful. Irritated though he may be by overprotectiveness, encroachment, parental fear of filial autonomy, he must always describe them as expressions of love, or of the understandable desire to maintain the unity of a family exposed to so much stress and the threat of dissolution.

In much the same way he must also lend a positive connotation to the patient's symptom. To that end, he will use what material he has collected to prove that the patient keeps sacrificing herself, albeit unwittingly, for a completely unselfish end: the cause of family unity.

This first and fundamental step in the practice of positive connotation is full of implicit messages:

The therapist ensures or consolidates his superior position on the hierarchial scale. This is because, in Western culture at least, a disapproving authority casts doubts on its self-assurance (as witness those pseudo-authorities who dispense punishments and prohibitions for the sole purpose of making their presence felt). An approving authority, by contrast, and one, moreover, that explains the motives of its approbation, is clearly one that has no doubts about its rationality.
The therapist shows that the entire group is engaged in a single pursuit, namely the preservation of the unity and stability of the family. This connotation, however, introduces an implicit absurdity: how can something so won derful and normal as family unity exact so abnormally high a price as anorexia?
The therapist gently displaces the patient from her customary position to one that is complementary in the game, and, in so doing, alters the respective roles of all the members: he shows that the patient is so sensitive and generous that she cannot help sacrificing herself for her family, much as the others cannot help sacrificing themselves for the same ends.
The therapist keeps stressing the compulsive nature of the symptom ("the patient cannot help sacrificing herself") but takes care to underplay the harmful aspect by defining the symptom as something beneficial to the whole system. At the same time he also defines as "symptoms" the behavior patterns of the other family members (they, too "cannot help themselves" if the family is to stay together) and gives these "symptoms" the same positive connotation.

The way is now open for the decisive therapeutic step: the therapeutic paradox. The symptom, defined as essential to family stability, is prescribed to the patient by the therapist, who advises her to continue limiting her food intake, at least for the time being. The relatives, for their part, are also instructed to persist in their customary behavior patterns.

The result is a situation that is paradoxical in several respects, the first of which is quite obvious: the family has consulted the therapist and is paying him for the sole purpose of ridding the patient of her symptom, and all he apparently does in return is not only to approve of this symptom but actually to prescribe it!

Moreover the therapist, by prescribing the symptom, implicitly rejects it as such. Instead, he prescribes it as a spontaneous action that the patient cannot, however, perform spontaneously, and this precisely because it has been prescribed. Hence the patient is driven into a corner from which she can only escape by rebelling against the therapist, that is, by abandoning her symptom. In that case she may return to her next session looking better, only to find that the therapist fails to reprove her --- yet another paradox.

A series of such moves proved so successful with three patients during the very first session, that they soon afterwards dropped their symptom. In general, however, we prefer to hasten more slowly. Active tactical interventions designed quite specifically to elicit significant responses from the family have been described in the last chapter, but as our work has advanced, and with it our understanding of the epistemological error responsible for the malfunctioning of such families, we have gone on to devise other tactics.

The most important and effective of these is the one that follows the cybernetic model more closely. It calls for the prescription of family rituals. Let me mention two concrete examples.

The first family to whom we applied the new strategy was not one with an anorexic member, but one with a six-and-half-year-old son whose aggressive behavior bordered on the psychotic. I mention it here because it is so clear-cut.

The child, whose EEG had shown minimal brain damage, was brought to family therapy when a child psychoanalyst refused to continue his treatment. The child seemed totally inaccessible to psychoanalytic approaches and, moreover, intolerably hostile. After four sessions with the parents, two in the presence of the child, the therapists realized that, apart from being exposed to intense interparental conflicts, the child had been forced into a double bind situation from which he could not extricate himself. Labeled "sick" by the neurologists and having been doctored with massive doses of sedatives, he was treated like a maniac at home and hence allowed to behave in a way that no parents would have taken from normal children, such as vicious kicks at the mother's face as she bent down to tie his shoelaces, lunges with the table-knife, and plates of soup over the mother's dress. By contrast he was invariably treated to long sermons and reproaches about his past misdeeds whenever he behaved like a normal child of his age. The therapists saw quickly that their first move must be the eradication of this double bind situation, and this by destroying the parents' conviction that their child was "mental." But they also realized that they could not achieve this end by verbal explanations, which would have been disqualified there and then. Instead they decided to prescribe the following family ritual: that same evening, after supper, the entire family, consisting of the father, the mother, the patient, his little sister, and the maternal grandmother, would go in procession to the bathroom, the father carrying all the child's medicine bottles and solemnly addressing the following words to his son:

Today we were told by the doctors that we must throw all these medicines away because you are perfectly well. All you are is a naughty child, and we simply won't take any more of your nonsense.

Thereupon he would pour the contents of the bottles, one by one and with great ceremony, down the lavatory, all the time repeating: "You are perfectly well." This ritual proved so effective (notwithstanding the mother's fears that the child would kill her without his sedatives) that it led to the disappearance of the aggressive behavior and, soon afterwards, to an amicable solution of the secret interparental conflicts (ten sessions).

Another ritual, this time repetitive, was prescribed to a family with a grave anorexic patient, whom we shall call Nora, and who, during the course of family therapy, had tried to commit suicide so effectively that she had to be resuscitated. This attempt showed that her therapists had made a serious miscalculation: they had focused attention so exclusively on her nuclear family as to miss the secret rule that nothing but good must be spoken of any members of Nora's extended family, a close-knit and powerful clan. It was only during the dramatic session following Nora's suicide attempt that her elder sister dropped some vague remarks about Nora's particularly "difficult" relations with one of her female cousins. Apparently the latter, backed by her mother, and envious of Nora's undoubted good looks, treated Nora with a mixture of affection and great cruelty. Both parents immediately hastened to repair the damage by harping at length on the angelic goodness of the cousin, "a real sister to our Nora." This caused Nora, who had never before mentioned the cousin to us, to speak of her throughout the rest of the session. She had clearly come to distrust her own feelings: if the cousin seemed spiteful and nasty, it was, no doubt, because she, Nora, was herself spiteful, envious, and bad.

In their meeting after the session, the therapists decided to keep their new knowledge to themselves, and not to engage in what were bound to be futile discussions. Instead they decided to prescribe the following ritual.

In the fortnight before the next session, Nora's family would lock the front door immediately after dinner on alternate days and sit around the table for an hour. A clock would be placed in the middle of the table, and every family member, in order of seniority, would have fifteen minutes to vent his own feelings and views, not least about other members of the clan. While any one was speaking the rest must not interrupt, let alone contradict. Moreover, whatever was said at the table must not be discussed outside the fixed ritual hour.

In this case, too, the ritual proved so effective that the treatment could be terminated in a total of fifteen sessions.

§ § §

We can now explain what precisely we mean by family ritual.

From a formal point of view, a family ritual is an action, or a series of actions, accompanied by verbal formulæ and involving the entire family. Like every ritual it must consist of a regular sequence of steps taken at the right time and in the right place.

Ritualization may smack of the magical or the religious, but this is not necessarily a disadvantage. It should, however, be stressed that the idea of prescribing a ritual was originally suggested by ethology, and quite particularly by certain intraspecific submission rituals whose sole purpose it is to convey placatory messages. The primary aim is to cure the patient with the help of a group engaged in a common task, that is the performance of the ritual.

We have found that the physical enactment of a ritual is infinitely more productive of positive change than any form of verbalization can hope to be. To return to one of our examples, had we merely told the parents of our little "maniac" that their son was not really ill, and that they must not treat him as an invalid, we should never have effected so rapid a cure. But by uniting the whole family in a carefully prescribed ritual, culminating in the destruction of the child's medicines, to the repeated cry of "You are perfectly well," we were able to introduce a powerful collective motive and hence a new normative system. In that sense the ritual may be said to work because it persuades the whole group to strive towards a common goal.

In this connection I must stress the widespread use of rituals in modern China. These do not consist of verbal formulæ and slogans to which the individual can turn a deaf ear through selective inattention, but try to foster the idea of social and family coöperation by means of dances, plays, and other public entertainments including, paradoxically enough, a whole range of competitive sports.

The "invention" of a family ritual invariably calls for a great creative effort on the part of the therapist and often, if I may say so, for flashes of genius, if only because a ritual that has proved effective in one family is unlikely to prove equally effective in another. This is because every family follows special rules and plays special games. In particular, a ritual is not a form of metacommunication about these rules, let alone about these games; rather it is a kind of countergame that, once played, destroys the original game. In other words, it leads to the replacement of an unhealthy and epistemologically false rite (for example the anorexic symptom) by one that is healthy and epistemologically sound.

I am absolutely convinced that mental "symptoms" arise in rigid homeostatic systems and that they are the more intense the more secret is the cold war waged by the subsystem (parent-child coalitions). We know that such pathological systems are governed by secret rules that shun the light of day and bind the family together with pathological ties.

In other words psychiatric "symptoms" tend to develop in family systems threatened with collapse; in such systems they play the same part as submission rites play in the animal kingdom: they help to ward off aggression from one's own kind. There is just this tragic difference: the specific human rite, called "illness," acquires its normative function from the very malfunction it is trying to eliminate.