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Psychosomatic Families: Anorexia Nervosa in Context
BOOK REVIEWS Psychosomatic Families: Anorexia Nervosa in Context By Salvador Minuchin, Bernice L. Rosman. and Lester Baker. 35\ pp. $15. Cambridge. Harvard University Press. \978.
• This book elicits all kinds of antithetical feelings and impressions. First, there is no doubt that the authors really know anorexia nervosa. They have the feel of it; they convey the "smell" of it; they are diagnostically keen. This is reason enough to buy and read this book. But it is also a book that engages in polemics against other styles and approaches to therapy. This interferes with reception of what the researchers have to offer. For example, they repeatedly use the terms "linear" or "dynamic" therapist as descriptions of contempt. On the other hand, they sing the praises of Palazzoli and her coworkers who, although psychoanalysts, created "a new model based on general systems theory, communication and cybernetics." This, of course, is the model the authors espouse. I found minimal mention of Hilde Bruch, whose extraordinary book Eating Disorders invites comparison. The book stands on its excellent descriptive material. If the authors have indeed obtained the results they claim, then it is on some basis other than their declared intervention. They claim, quite properly, that there is pathology in the entire family and not just in the patient. Who could quarrel with that? But their approach is largely confrontational. I question not only the efficacy of this, but whether it can even be termed "therapeutic." 132
It is an interesting strategy to meet with the family at lunch. It suggests to me-one of the "linear" and "dynamic" psychiatrists the authors criticize-that this problem is rooted in an early and overwhelming power struggle over food intake, and one in which the mother has been relentless. The anorexic child then becomes relentlessly oppositional. But meanwhile her entire concept of the world has become distorted. If massive unreality is psychosis, that is what the anorectic suffers; for her the world becomes a dangerous place that forces unwelcome things into her interior, a process she finds virtually impossible to resist. Minuchin and his coauthors are excellent in conveying what goes on in relation to power and control. One of the patterns they point to is the rigidity of the family interactions. They also convey the surface pleasantness and niceness of the family of the anorectic child, which covers the raging angers and aggressive interactions underneath. As they point out, "Many psychosomatic families deny the existence of any problems whatsoever, see 'no need' to ever disagree, and are highly invested in consensus and harmony." The members of these families appear to welcome help, appear to be open to change, but like waves, they surge back again to the same place, making the therapeutic task a difficult one indeed. Another excellent description conveys the authors' understanding: "The anorectic child has grown up in a family operating with highly enmeshed patterns. As a result, her orientation toward life
gives prime importance to proximity in the interpersonal contact. Loyalty and protection take precedence over autonomy and self-realization." Further, "with the child's entrance into adolescence, she finds herself in a crisis. Her wish to participate with a group of peers conflicts with her orientation to the family." But the "linear" or "dynamic" psychiatrists would have to add that there is more to the problem, for the adolescent anorectic fears contact with peers, and has developed no phase-adequate behavior. Yet Minuchin is "interested in symptom cessation-the what, not the why." And he criticizes Bruch for excluding parents from the therapeutic focus, although "their input is recognized." Incredibly, the statement is made that "unfortunately, the focus on the exploration of the relationship with significant figures in the past may bar fast recovery." And: "Furthermore, many anorectic adolescents develop chronic anorexia when treated with psychodynamic methods." These are examples of the bias that detracts from the book. Half of the book is devoted to detailed case histories, and includes the verbal intervention of the therapist. This degree of detail, often circuitous and repetitious, is not very productive; although for the persistent reader, it makes it possible to observe-and, it is necessary to add, to criticize-the therapeutic style. But the book also includes practical considerations of the over-all therapeutic approach. Here one cannot help but feel that PSYCHOSOMATICS
the anorectic patient must cope with new power operations in place of the old parental ones. Is their approach, as the authors claim, a "systems model [which) demands a quantum jump: acceptance that dependency and control, attraction and aggression, symbiosis and avoidance, are more than introjects"? Is this such a quantum jump for others of different theoretical and therapeutic persuasion? I doubt it. Yet it is possible, in good conscience, to urge readers to buy this book, because they will learn a lot observationally, even as I would be inclined to suggest that they tum to Hilde Bruch for profundity and a therapeutic approach that does not promise too much too quickly but which properly applied is likely to bear fruit. Natalie Shainess, M.D. New York
Trance and Treatment-Clinical Uses of Hypnosis By Herbert Spiegel and David Spiegel. 382 pp. $18.50. New York. Basic Books. 1978.
• This is a book that had to be written. Until it was, there was no compendium of the theories and techniques that have made Herbert Spiegel so influential in the field of hypnosis. Like Charcot and Janet, the Spiegels feel that certain personality types are likely to have similar symptoms. They state further that certain symptoms are responsive to hypnosis, and therefore the associated personality types are more FEBRUARY 1979 • VOL 20 • NO 2
hypnotizable; and that Spiegel's Hypnotic Induction Profile predicts hypnotizability, confinns personality style, and prescribes the treatment program. The Spiegel personality theory is that all humanity is divided into three groups: the obsessive-compulsive intellectualizing and analytical Apollonians; the here-andnow feeling-oriented and basically hysterical Dionysians; and the somewhat depressive and midrange Odysseans. The Apollonians have little capacity for hypnosis and are referred elsewhere for analysis or "biological treatment." The Dionysians have a good capacity for hypnosis and have led Spiegel to his goal of "single session treatment." The Odysseans are both qualitatively and quantitatively different; they present the problems in treatment. The Spiegel theory of hypnosis involves the ability to maintain attention. It is based on the eye roll (ER) sign as indicating the biologic ability to enter the trance. Environmental influences are revealed by the "reactive sensorimotor phenomena" of performance items such as arm levitation and "control dissociation." If the performance items-which follow the eye roll test and become a part of the induction process-are compatible with the ER, the Hypnotic Induction Profile (HIP) is said to be "intact," the patient is likely to be a Dionysian, to be in a trance, to be responsive to hypnosis, and to have a high "induction score" based on the HIP and the ER. If these items (ER and performance) are not compatible, the HIP is "nonintact" and either
"decrement" or "soft"; the patient is not as likely to be able to utilize hypnosis. In other words, if a patient enters a trance he is hypnotizable; if he does not, then he is not hypnotizable. A typical visit to Spiegel, especially for a Dionysian, would involve a five-minute history, administration of Spiegel's "Cluster Survey" to determine personality type (10 minutes), administration of the ER and HIP, administration of "dialectical" therapy either in person or by tape recorder ("Why spend the time listening to the patient? It is better to let the patient be quiet and listen to the therapist"), and a prescription to practice hypnosis and repeat the magic words 15 to 20 times daily. No return visit is required. All in all, the book is well-written, clear, well-organized, often intentionally amusing, and always sincere. It is interesting, innovative, provocative. The Spiegels put their philosophy, theory, and methods right on the line, and they present both the supporting and the refuting evidence. All serious students of hypnosis should read this book and try the Spiegel system. But the book can be put into its proper perspective only by a person well-grounded in personality theory, psychopathology, and basic traditional hypnosis. The true Spiegelian believer will see this as a primary-intermediate text. The more traditional therapist will find himself challenged and will use it adj unctively. James R. Hodge. M.D. University 0/ Akron Akron. Ohio IJJ
• This book elicits all kinds of antithetical feelings and impressions. First, there is no doubt that the authors really know anorexia nervosa. They have the feel of it; they convey the "smell" of it; they are diagnostically keen. This is reason enough to buy and read this book. But it is also a book that engages in polemics against other styles and approaches to therapy. This interferes with reception of what the researchers have to offer. For example, they repeatedly use the terms "linear" or "dynamic" therapist as descriptions of contempt. On the other hand, they sing the praises of Palazzoli and her coworkers who, although psychoanalysts, created "a new model based on general systems theory, communication and cybernetics." This, of course, is the model the authors espouse. I found minimal mention of Hilde Bruch, whose extraordinary book Eating Disorders invites comparison. The book stands on its excellent descriptive material. If the authors have indeed obtained the results they claim, then it is on some basis other than their declared intervention. They claim, quite properly, that there is pathology in the entire family and not just in the patient. Who could quarrel with that? But their approach is largely confrontational. I question not only the efficacy of this, but whether it can even be termed "therapeutic." 132
It is an interesting strategy to meet with the family at lunch. It suggests to me-one of the "linear" and "dynamic" psychiatrists the authors criticize-that this problem is rooted in an early and overwhelming power struggle over food intake, and one in which the mother has been relentless. The anorexic child then becomes relentlessly oppositional. But meanwhile her entire concept of the world has become distorted. If massive unreality is psychosis, that is what the anorectic suffers; for her the world becomes a dangerous place that forces unwelcome things into her interior, a process she finds virtually impossible to resist. Minuchin and his coauthors are excellent in conveying what goes on in relation to power and control. One of the patterns they point to is the rigidity of the family interactions. They also convey the surface pleasantness and niceness of the family of the anorectic child, which covers the raging angers and aggressive interactions underneath. As they point out, "Many psychosomatic families deny the existence of any problems whatsoever, see 'no need' to ever disagree, and are highly invested in consensus and harmony." The members of these families appear to welcome help, appear to be open to change, but like waves, they surge back again to the same place, making the therapeutic task a difficult one indeed. Another excellent description conveys the authors' understanding: "The anorectic child has grown up in a family operating with highly enmeshed patterns. As a result, her orientation toward life
gives prime importance to proximity in the interpersonal contact. Loyalty and protection take precedence over autonomy and self-realization." Further, "with the child's entrance into adolescence, she finds herself in a crisis. Her wish to participate with a group of peers conflicts with her orientation to the family." But the "linear" or "dynamic" psychiatrists would have to add that there is more to the problem, for the adolescent anorectic fears contact with peers, and has developed no phase-adequate behavior. Yet Minuchin is "interested in symptom cessation-the what, not the why." And he criticizes Bruch for excluding parents from the therapeutic focus, although "their input is recognized." Incredibly, the statement is made that "unfortunately, the focus on the exploration of the relationship with significant figures in the past may bar fast recovery." And: "Furthermore, many anorectic adolescents develop chronic anorexia when treated with psychodynamic methods." These are examples of the bias that detracts from the book. Half of the book is devoted to detailed case histories, and includes the verbal intervention of the therapist. This degree of detail, often circuitous and repetitious, is not very productive; although for the persistent reader, it makes it possible to observe-and, it is necessary to add, to criticize-the therapeutic style. But the book also includes practical considerations of the over-all therapeutic approach. Here one cannot help but feel that PSYCHOSOMATICS
the anorectic patient must cope with new power operations in place of the old parental ones. Is their approach, as the authors claim, a "systems model [which) demands a quantum jump: acceptance that dependency and control, attraction and aggression, symbiosis and avoidance, are more than introjects"? Is this such a quantum jump for others of different theoretical and therapeutic persuasion? I doubt it. Yet it is possible, in good conscience, to urge readers to buy this book, because they will learn a lot observationally, even as I would be inclined to suggest that they tum to Hilde Bruch for profundity and a therapeutic approach that does not promise too much too quickly but which properly applied is likely to bear fruit. Natalie Shainess, M.D. New York
Trance and Treatment-Clinical Uses of Hypnosis By Herbert Spiegel and David Spiegel. 382 pp. $18.50. New York. Basic Books. 1978.
• This is a book that had to be written. Until it was, there was no compendium of the theories and techniques that have made Herbert Spiegel so influential in the field of hypnosis. Like Charcot and Janet, the Spiegels feel that certain personality types are likely to have similar symptoms. They state further that certain symptoms are responsive to hypnosis, and therefore the associated personality types are more FEBRUARY 1979 • VOL 20 • NO 2
hypnotizable; and that Spiegel's Hypnotic Induction Profile predicts hypnotizability, confinns personality style, and prescribes the treatment program. The Spiegel personality theory is that all humanity is divided into three groups: the obsessive-compulsive intellectualizing and analytical Apollonians; the here-andnow feeling-oriented and basically hysterical Dionysians; and the somewhat depressive and midrange Odysseans. The Apollonians have little capacity for hypnosis and are referred elsewhere for analysis or "biological treatment." The Dionysians have a good capacity for hypnosis and have led Spiegel to his goal of "single session treatment." The Odysseans are both qualitatively and quantitatively different; they present the problems in treatment. The Spiegel theory of hypnosis involves the ability to maintain attention. It is based on the eye roll (ER) sign as indicating the biologic ability to enter the trance. Environmental influences are revealed by the "reactive sensorimotor phenomena" of performance items such as arm levitation and "control dissociation." If the performance items-which follow the eye roll test and become a part of the induction process-are compatible with the ER, the Hypnotic Induction Profile (HIP) is said to be "intact," the patient is likely to be a Dionysian, to be in a trance, to be responsive to hypnosis, and to have a high "induction score" based on the HIP and the ER. If these items (ER and performance) are not compatible, the HIP is "nonintact" and either
"decrement" or "soft"; the patient is not as likely to be able to utilize hypnosis. In other words, if a patient enters a trance he is hypnotizable; if he does not, then he is not hypnotizable. A typical visit to Spiegel, especially for a Dionysian, would involve a five-minute history, administration of Spiegel's "Cluster Survey" to determine personality type (10 minutes), administration of the ER and HIP, administration of "dialectical" therapy either in person or by tape recorder ("Why spend the time listening to the patient? It is better to let the patient be quiet and listen to the therapist"), and a prescription to practice hypnosis and repeat the magic words 15 to 20 times daily. No return visit is required. All in all, the book is well-written, clear, well-organized, often intentionally amusing, and always sincere. It is interesting, innovative, provocative. The Spiegels put their philosophy, theory, and methods right on the line, and they present both the supporting and the refuting evidence. All serious students of hypnosis should read this book and try the Spiegel system. But the book can be put into its proper perspective only by a person well-grounded in personality theory, psychopathology, and basic traditional hypnosis. The true Spiegelian believer will see this as a primary-intermediate text. The more traditional therapist will find himself challenged and will use it adj unctively. James R. Hodge. M.D. University 0/ Akron Akron. Ohio IJJ