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Unlocking the Family Door: A Systemic Approach to the Understanding and Treatment of Anorexia Nervosa
BOO K AND M ED IA RE VIEW
I suspect that they are very dynamic in their work with parents and adolescents. RICH ARD M . SARLE S . M.D. Director, Division of Child and Adolescent Psychiatry The Sheppard and Enoch Pratt Hospital. Clinical Prof essor of Psychiatry and Pediatrics Universi ty of Maryland School of Medici ne
Unlocking the Family Door: A Systemic Approach to the Understanding and Treatment of Anorexia Nervosa . By Helm Stierlin and Gunth ard Weber. New York : Brunner/Mazel, 1989,256 pp . , $27 .50 (hardback) . Dr. Stierlin's previous books (Psychoanalysis and Famil y Therapy, 1977; Sep arating Parent s and Adole scent s, 1981; and The First Intervi ew in Famil y Therapy, 1980) have been practical guides to understandin g complex treatm ent techniques and the theory behind these techniques . In this book, Dr. Stierlin joins with a co lleag ue, Dr. Webe r, to produce a highly readabl e , at times entertaining, and always educational summary of their work with anorexia nervosa families. The title for this book comes from the authors' finding that many anorectic families have doors which prevent certain children from reach ing mature autonomy. Instead these doors establish togetherness where there is a threat of separation. The authors demonstrate throughout the book how they attempt to open the enmes hed family doors to help undo the extreme ded ication to family cohesion. The case history of a 19-year-old, 70-pound anorec tic girl clea rly dem onstrates the authors' approach to fam ilies . In this case, the family is seen for 12 interviews over 14 months. The " circular questioning approach" is used with this family to direct the family to dealing with the patient ' s " hunger strike" in relation to the fam ily's preoccupation with selfsacrifice and denial. The 12 family interviews are eac h summarized so that the reader may follow the therapists' efforts to reorganize the fam ily relation ships . The authors recog nize that progress is very limited . In fact a 2-yea r follow-up showed that the patient was still living at home , but had gained 20 pounds and was " beginning " the separation proce ss. The techn ique promoted throughout the book is "systemic therapy," an approac h to families which takes into account the circularity and recursiveness of relational processi ng. The entir e family system is treated in all its mutual interrelation ships. Spec ific techniques of systemic therapy include the circular questioning approach, a dry family lunch, and focus upon separa tion - individ uation issues in eac h family in order to " trigge r new construc tions of reality." Although the authors have intensive 2-hour sessions with families, they meet for only 10 sessions over I or 2 yea rs. The authors try to act as cata lysts to provoke separation and individuation processes which the families must carry out between sessions. In a chapter titled "Lessons from a Follow -up Study, " the authors present the result s of their l.Am .Acad. Child Adolesc . Psychiatry, 29:2. March 1990
treatment of 42 families. They share successes and failures in this follow-up study. Nearly 80% of the adolesce nt girls were menstruating and had "indivi duated in acco rdance with their age," although 42 % still had dysfunctional families. Throughout the book , clinical material is present ed in a crisp, thoughtful manner so that the read er can clearly understand the authors' therapeut ic strategy . Several introductory chapters exp lain the origi ns and strategies of systemic family therapy. Ove rall, the book is a useful addition to the library of clinicia ns work ing with anorec tic patients and families . MICHAEL J. MALONEY . M.D . Associate Prof essor of Child Psychiatry & Pediatrics University of Cincinnati College of Medicine Director, Child Psychiatry and Psychology Children' s Hospital Medical Center, Cincinnati
Families in Perpetual Crisis. By Richard Kagan and Sh irley Schlosberg. New York: W. W . Norton & Company. 1989. 224 pp. , $ 19.95 (cloth) . Th is book is intended for family workers in soc ial service agencies and mental health settings . It is based on a model of family work that the authors developed in the Prevent ion Program of Parsons Child and Family Center , Albany, New York. The authors point out that between a quart er to half a million American child ren are said to be living in foster homes, group homes, and residential treatment centers. More than one in fou r of these children move through three or four consecut ive placeme nts. Children who lack the stability of perman ent relationships with adults often " beco me so anxious that they " are not able to master the ski lls needed to be competent and stable adults. These children are in great need of preventi ve services in the form of " pe rmanency planning." The authors point out that instead of staying in "limbo" in foster homes or residenti al treatment centers for prolonged periods. these children need to be anchored em otionally to bio logical parents or adoptive families with appropriate work on " grieving " for the losses that they have experie nced. In the early chapters of the book , the authors elucidate the dynam ics of families in perp etual crisis because these are the types of families that face placem ent of children away from the famil y for a variety of reasons. The discussions are suppleme nted by detailed case descript ions. The best part of the book in this reviewer 's opinio n is chapter nine , titled " Building Famil y Conn ections for the Child Who Cann ot Go Home. " Here the authors discuss in detail the mechanisms of introducing placement to the child and the family as well as the types of the communication techniques to use in indivi dual work with children. They strongly advocate " home-based family assessment " which is generall y well acce pted, and the concept of "open adoption " which allows the parent and child to maint ain a con323
I suspect that they are very dynamic in their work with parents and adolescents. RICH ARD M . SARLE S . M.D. Director, Division of Child and Adolescent Psychiatry The Sheppard and Enoch Pratt Hospital. Clinical Prof essor of Psychiatry and Pediatrics Universi ty of Maryland School of Medici ne
Unlocking the Family Door: A Systemic Approach to the Understanding and Treatment of Anorexia Nervosa . By Helm Stierlin and Gunth ard Weber. New York : Brunner/Mazel, 1989,256 pp . , $27 .50 (hardback) . Dr. Stierlin's previous books (Psychoanalysis and Famil y Therapy, 1977; Sep arating Parent s and Adole scent s, 1981; and The First Intervi ew in Famil y Therapy, 1980) have been practical guides to understandin g complex treatm ent techniques and the theory behind these techniques . In this book, Dr. Stierlin joins with a co lleag ue, Dr. Webe r, to produce a highly readabl e , at times entertaining, and always educational summary of their work with anorexia nervosa families. The title for this book comes from the authors' finding that many anorectic families have doors which prevent certain children from reach ing mature autonomy. Instead these doors establish togetherness where there is a threat of separation. The authors demonstrate throughout the book how they attempt to open the enmes hed family doors to help undo the extreme ded ication to family cohesion. The case history of a 19-year-old, 70-pound anorec tic girl clea rly dem onstrates the authors' approach to fam ilies . In this case, the family is seen for 12 interviews over 14 months. The " circular questioning approach" is used with this family to direct the family to dealing with the patient ' s " hunger strike" in relation to the fam ily's preoccupation with selfsacrifice and denial. The 12 family interviews are eac h summarized so that the reader may follow the therapists' efforts to reorganize the fam ily relation ships . The authors recog nize that progress is very limited . In fact a 2-yea r follow-up showed that the patient was still living at home , but had gained 20 pounds and was " beginning " the separation proce ss. The techn ique promoted throughout the book is "systemic therapy," an approac h to families which takes into account the circularity and recursiveness of relational processi ng. The entir e family system is treated in all its mutual interrelation ships. Spec ific techniques of systemic therapy include the circular questioning approach, a dry family lunch, and focus upon separa tion - individ uation issues in eac h family in order to " trigge r new construc tions of reality." Although the authors have intensive 2-hour sessions with families, they meet for only 10 sessions over I or 2 yea rs. The authors try to act as cata lysts to provoke separation and individuation processes which the families must carry out between sessions. In a chapter titled "Lessons from a Follow -up Study, " the authors present the result s of their l.Am .Acad. Child Adolesc . Psychiatry, 29:2. March 1990
treatment of 42 families. They share successes and failures in this follow-up study. Nearly 80% of the adolesce nt girls were menstruating and had "indivi duated in acco rdance with their age," although 42 % still had dysfunctional families. Throughout the book , clinical material is present ed in a crisp, thoughtful manner so that the read er can clearly understand the authors' therapeut ic strategy . Several introductory chapters exp lain the origi ns and strategies of systemic family therapy. Ove rall, the book is a useful addition to the library of clinicia ns work ing with anorec tic patients and families . MICHAEL J. MALONEY . M.D . Associate Prof essor of Child Psychiatry & Pediatrics University of Cincinnati College of Medicine Director, Child Psychiatry and Psychology Children' s Hospital Medical Center, Cincinnati
Families in Perpetual Crisis. By Richard Kagan and Sh irley Schlosberg. New York: W. W . Norton & Company. 1989. 224 pp. , $ 19.95 (cloth) . Th is book is intended for family workers in soc ial service agencies and mental health settings . It is based on a model of family work that the authors developed in the Prevent ion Program of Parsons Child and Family Center , Albany, New York. The authors point out that between a quart er to half a million American child ren are said to be living in foster homes, group homes, and residential treatment centers. More than one in fou r of these children move through three or four consecut ive placeme nts. Children who lack the stability of perman ent relationships with adults often " beco me so anxious that they " are not able to master the ski lls needed to be competent and stable adults. These children are in great need of preventi ve services in the form of " pe rmanency planning." The authors point out that instead of staying in "limbo" in foster homes or residenti al treatment centers for prolonged periods. these children need to be anchored em otionally to bio logical parents or adoptive families with appropriate work on " grieving " for the losses that they have experie nced. In the early chapters of the book , the authors elucidate the dynam ics of families in perp etual crisis because these are the types of families that face placem ent of children away from the famil y for a variety of reasons. The discussions are suppleme nted by detailed case descript ions. The best part of the book in this reviewer 's opinio n is chapter nine , titled " Building Famil y Conn ections for the Child Who Cann ot Go Home. " Here the authors discuss in detail the mechanisms of introducing placement to the child and the family as well as the types of the communication techniques to use in indivi dual work with children. They strongly advocate " home-based family assessment " which is generall y well acce pted, and the concept of "open adoption " which allows the parent and child to maint ain a con323