Anorexia --- A Case Study

We now come to a clinical example that illustrates our method of intervening in the most rigid possible type of family organization: a family with an adolescent anorectic member. As I have said elsewhere, these families are tied down by such fixed rules that they can be compared with a programmed cybernetic machine. Thus the clinical case I am about to describe involves a family so incapable of changing its rules that it reacts with even greater rigidification to all calls for change addressed to it from the outside (the social environment) and to all stimuli from the inside (adolescent changes of a member).

To produce an effective change in this type of family we made use of interventions of the paradoxical type as early as the end of the first session. I must, however, stress that such interventions demand a high degree of skill on the part of the therapist: he must conduct the sessions in such a way as to elicit the greatest possible amount of information about the ongoing types of relationships in the family. As for the intervention itself, it must be carefully analyzed in the light of the theoretical model used, in our case the systemic model.

The family under consideration, whom we shall call the Ferrarinas, was made up of three members, Pia, the identified patient, being the daughter. At the time when the family contacted our Center, Pia was in a hospital ward for gravely emaciated patients. The parents, with the consent of the physician in charge, brought Pia from the hospital to attend the first session. Pia was 17 years old and had been an anorectic for a year.

I now shall sum up the fundamental data collected by the therapist during the first session. The parents were of different social backgrounds. The mother, a factory worker, came from a poor family. The father, by contrast, came from a rich and well-known family in which he had always been the "black sheep," having cut short his studies and having lost enormous sums at gambling tables. To his family, the marriage to a factory worker was another tangible sign of failure.

Once married, the two moved into a small apartment, which they owned, holding a mortgage. The family income consisted of the wife's wages and the somewhat chancy earnings of the husband, who had taken a job as a commercial traveler. Gina, the wife, had devoted herself body and soul to her husband's rehabilitation. It was she who found him clients, who encouraged him to work, and brought him back home if he stayed too long in the bar.

But quite soon the "gambling demon" resumed its grip on him. One day, when Pia was six years old, an eviction order arrived: Augusto, the husband, had lost everything at roulette, including his home. Gina, disheartened but not defeated, found lodgings for herself and her daughter with a lady whose linen she took care of at the end of her factory day. Augusto slept here and there, living hand to mouth.

A few years later the family was reunited, but life remained difficult. Augusto did not have a regular income and from time to time he still gambled, although more rarely, and for small sums. As if to make up for it, Pia was a model girl, a great consolation to her mother, who spared no sacrifice to make sure that her daughter lacked for nothing. Pia studied hard for a secretary's diploma.

The period preceding the outbreak of the anorectic symptom was marked by the following events:

Pia, having obtained her diploma, joined a bank and began to earn her living, associated with boys and girls of her own age, and began to go out with them in her free time, sometimes in the evening. The mother invariably waited up for her. The father, now employed as a representative at a very prosperous company, was earning more and handed his wife fairly large amounts of money, but continued to go out almost every night. The wife, for her part, no longer minded; she felt strangely indifferent to her husband's comings and goings. He went out. He didn't go out. To her it was all the same. All her interest was centered on Pia, on the new life that Pia had begun: her colleagues at the bank, her telephone calls, her late nights.

It was during that period that Pia, copying some girl friends (who wore tight jeans) began to go on a diet. Her loss of weight became very dramatic, and there was no longer any way of stopping it. In vain the mother implored her, cried, began to cook special dishes.

I now come to the therapist's paradoxical intervention at the end of the first session.

Therapist(turning to the mother): We have all been touched by Pia's concern for you, Signora Ferrarina. It is for your sake that Pia is doing it all. It's because you, Signora Ferrarina, have always been a courageous woman with high moral standards, a woman who stands firm in the face of adversity, who helps others without ever bothering about herself. The story of your life speaks volumes. You have devoted your best years to helping your husband, you have slaved away to make sure your family wants for nothing. Sacrificing yourself for others lends meaning to your life, is your aim. We think that, recently, when things eased up for you (your husband earning enough, his nightly outings no longer causing you suffering, Pia herself having a good job ... ), Pia began to feel, perhaps unconsciously, that a grave threat hung over the family: you might finish up feeling that you had become useless, empty, devoid of reasons to continue the struggle. Perhaps she feared you would become depressed. To avoid that, Pia decided to become anorectic --- the best way of making sure that you, Signora, could still feel that you were being a mother, could still feel needed, could still feel in harness. That is why Pia renounced her beauty, her work, and many other things as well.

Mother: But I am ready to commit suicide if only my daughter could become cured! [A dreadful slip, not pointed out by the therapist.]

Therapist: We think that Pia is so convinced of the need to look after you, Signora Ferrarina, that she will continue to behave as she is doing. No one has asked her to do it ... it is her own free choice, and we respect her for it. [The therapists fix the date of the next session, a month ahead, and take their leave.]

The pragmatic effect of this intervention was immediate. That same evening (the session had been held in the morning) Pia's physician telephoned from the hospital to let us know that Pia had not only eaten the entire evening meal but had even asked for a second helping.

§ § §

Let us now analyze our intervention.

The parental couple had always had a symmetrical relationship, disguised as a complementary one. The martyred wife had struggled to get the better of her husband and to redeem him by her indefatigable sacrificial presence. The husband, for his part, had fought against the crushing power of the "gambling demon" (an interaction very similar to that of the alcoholic). In a pseudocomplementary escalation, each partner had reinforced the other's behavior. The more efficient the wife was, the more inefficient the husband became and the more of a slave to the gambling demon.

When Pia reached full adolescence, started to work, and entered into extrafamilial relationships, the system needed a change of rules. The mother should have renounced her rigid control, and the father should have helped his wife to cope with the new situation, filling the vacuum left by Pia. But the system had become too rigid to change. The mother could no longer renounce her position of supermother; the father had become too marginal a figure to intervene in a constructive way. Moreover, for his own peace of mind, he liked to think that Pia completely filled his wife's life. When Pia communicated a change in the definition of their relationship (she was independent, earned her own living, decided herself what to do with her free time), she was met with anguished rejection by her mother and with cryptic silence by her father.

At this point Pia's learning context sprang into action and suggested an infallible means of putting her mother down without declaring her hostility in the first person. And that is how, just as had happened with her father, a mysterious, deep, indefinable, invincible demon appeared on the scene and gained the upper hand over everyone. In Pia's case it was not a gambling demon but the demon of anorexia: "I too would like to eat but I cannot."

§ § §

Let us now list the fundamental facts underlying all these developments.

When the Ferrarinas appeared at the first session we observed the following phenomena:

All members of the family shared the false belief that, by virtue of her symptom, Pia had power over everybody.

Pia herself was under the misapprehension that she had assumed power over both her own body and the system.

Pia did not declare a hunger strike in her own name but in the name of an abstract entity: her disease.

That abstract entity was given a negative connotation: it was thought to be an evil.

Let us now analyze the therapists' intervention:

They gave a positive connotation to all forms of behavior they observed.

They praised the generosity and the spirit of sacrifice of a mother who had struggled so hard to free her husband from a demon that was stronger than he was, the gambling demon.

They defined as good the anorectic behavior of the designated patient, i.e., as an unselfish attempt to act in her mother's best interests.

They dethroned the mother from her position of super-mother and conferred on the daughter (for the first time in her life) a maternal role vis-a-vis her own mother: her fasting was presented as a means of protecting her mother against depression.

They deprived the daughter of her presumed superiority, placing her in a position of inferiority to her new vocation: that of helping her mother.

They allied themselves with the homeostatic tendency of the system, temporarily relinquishing any idea of changing it.

But in so doing they had already intervened in favor of a change. By revising the punctuation and connotation of the observed phenomena, they had introduced a circular view of the reciprocal relationships into the system. As a direct result, the systemic organization was upset, and the old game had to be abandoned.

The first result of this complex intervention, articulated on various levels, was Pia's revolt against her "vocation," so highly praised by the therapists; she dropped her symptom.

Once they had got rid of the symptomatic behavior, the therapists could proceed to the reorganization of the relationships.

To that end, they proceeded step by step: they observed the feedbacks, framed new hypotheses, thought up fresh interventions, tried to steer the family toward new experiences.

§ § §

Pia's case provides a helpful clarification of the most misunderstood aspect of the fundamental distinction between hypothesis and intervention.

When Pia attained physiological independence, she came up against her mother, a woman incapable of slackening their intense and privileged relationship and of dropping the role of heroic mother, which had become her survival mechanism. Opposition, albeit passive, also came from the father (in the form of a lack of support for Pia), who had used his wife's great devotion to the daughter as a means of escape. Strategically, Pia's anorexia was a move set off by resentment of the obstacles that had been put up in her path and also an attempt to win the game of "putting the mother down" with the help of the same ploy --- "It's not me but a force stronger than myself" --- that she had seen her father use with such success. Now, though this was our hypothesis, it was not reflected in the intervention, which was, in fact, aimed at repunctuating the meanings the actors themselves attributed to their behavior and to do it in such a way as to challenge and to ridicule that behavior.

Obviously, the therapists did not really believe that Pia wished to sacrifice herself for her mother. The intervention was a paradoxical comment intended to bring out Pia's hostility toward her mother and to challenge the family view of Pia's anorexia. Mara Selvini never thought that her patients were saints immolating themselves altruistically on the altar of family needs. This fact must nevertheless be stressed since there are many people, especially in the United States, who have mistaken Mara Selvini's paradoxical comments and positive connotations for so many expressions of a belief that the mentally ill nurse a sacrificial philosophy.

The fact that, in presenting her symptoms, the identified patient does not change the game and, indeed, frequently helps to perpetuate it, is not a sign of her benevolence but, on the contrary, reflects a determination not to violate the rules of the family game. In this connection I want to mention a statement by Mara Selvini (made during a discussion in 1983):Take the case of an anorectic girl. What a difference there is between an anorectic and a political prisoner who goes on a hunger strike! The rebel who goes on a hunger strike clearly defines the subject of his action, against whom it is directed, and its aim: "I am going on a hunger strike to force you, who wield political power, to change your definition of your relationship with my group or nation."

The anorectic, by contrast, behaves in quite a different way, defining neither the subject nor the addressee nor the aim. He [or she] simply reduces his food intake on the pretext that he has no appetite, that he suffers from nausea or digestive problems, or that he feels bloated. In so doing he plainly respects the family rule that no one ever takes any step in his own name; the symptom merely strengthens the family organization. This does not alter the fact that the maintenance of the status quo is not the result of benevolence on the part of the anorectic.

Every symptom, anorexia, attempted suicide, schizophrenia...shows that the situation is felt to be intolerable by the identified patient, who above all wants to punish the others for all the wrongs they have done him.

The fact that such interpretations are anything but arbitrary is borne out by the results of interventions advising patients to persevere: if Lina and Pia had really been filled with benevolence for their mothers (or interested in the homeostasis/coherence of the system) they would have maintained their symptoms instead of abandoning them as suddenly as they did.