- Email: [email protected]
Psychosomatic families. Anorexia nervosa in context
Book Reviews
Psychosomatic Families. Anorexia Nemosa in Context. By Salvador Minuchin, Bernice L. Rosman, and Lester Baker. Cambridge, Mass: Harvard University Press, 1978
Psychosomatic Families looks at anorexia nervosa from the vantage point of family therapy, which serves here both as a research tool and as a therapeutic modality. The authors are strongly convinced of the superiority of family therapy over other possible approaches, and this is the principal message of their presentation. The book is based on a study of 53 anorectic patients, most of them adolescent females, who were treated over a period of 7 years by 16 different therapists of varying levels of experience-senior psychiatrists, psychologists, social workers and psychiatric residents. Although over half of the patients were hospitalized initially, the authors believe that hospitalization should be avoided unless clearly mandated by the patient’s physical and emotional state. All the patients were treated first with family therapy, but some later received individual therapy as well. Pharmacotherapy played no significant role. In most cases, treatment was brief (several months); in a few instances, however, it lasted a year or longer. The authors achieved a very high rate of success. Of the 53 patients, 43 had a good outcome, 2 a fair outcome, and only 8 dropped out of treatment, relapsed or were unimproved. These results are considerably better than those of most other series, which report success in 40-60% of cases. The theoretical framework of Psychosomatic Families is that of systems theory. The locus of pathology is placed strictIy and squarely in the relationship between the identified patient and her family with its complex reverberating circuits of interpersonal pressures and counterpressures. The authors emphasize this bias by introducing the term 276
“anorectic family.” They are aware that this label is both unfelicitous and inaccurate, but they are so set on the view that the problem belongs with the family rather than with the identified patient, that they have chosen to stick with their term despite the objections inevitably to be raised. The principal characteristic of the “anorectic family” is “enmeshment.” This means that in the typical instance, there are insufficient boundaries both among the individual members and between generations. Intrusive and controlling parental behavior is the rule; the family is strongly child oriented, hypervigilant, overprotective, and controlling. These families are superficially harmonious; they deny interpersonal conflict and give loyalty and protection precedence over autonomy and self-realization. The future anorectic learns early to be compliant and good; anorexia thus becomes a logical battleground for struggles over control, autonomy, and individuation. Four cases are presented which focus on the therapists’ opening moves; their primary goal is to break up the power stalemate within the family which has permitted the patient to develop her anorexia to such dangerous proportions. A transcript of the first family session reveals the fundamental direction of treatment: to get the patient to eat and to redefine the problem as an interpersonal struggle centered on the issue of power. The approach is intensely active and deliberately confrontative, manipulative, and intrusive. The intent is not so much to clarify meanings as to change behavior, although in the course of these interactions, some important aspects of the non-eating behavior are inevitably clarified. The first behavior that USUally is addressed is the patient’s resolve not to eat. The therapist intervenes to upset the stalemate which supports the non-eating behavior, first by introducing himself into the previously closed system and then by lending his support and authority at different times to the various members of the General Hospital Psychiatry @ ElsevierNorthHolland,Inc., 1979
Book Reviews
family. The goal, ultimately, is to reduce enmeshment and stimulate the patient toward greater autonomy and self-realization. The authors see their own approach as innovative and radically different from earlier ones, of which they are often critical. In particular, they take exception with psychoanalytic and psychodynamic contributions. Psychoanalysts, they believe, have centered unduly on intrapsychic phenomena, and thus have emphasized irrelevancies instead of the real problem, namely, the often covert but powerful tensions between the patient and her family, in the present. The genetics of the patient’s difficulties, her fantasies, in fact her inner life are seen as of little moment. For the authors, the existence of a neurosis as a psychologic entity is overshadowed by the actual interpersonal struggles which, they feel, must be addressed directly if the patient’s condition is to be effectively treated. The issues raised here are complex and difficult to summarize in the brief space available; I will touch on only some major points. The book has very clear positives but also some insufficiencies that are equally apparent. Its strong suit is its forceful recognition of how family interactions influence and sustain the non-eating behavior. There are remarkably vivid portrayals of how patients behave in the context of their families and of how the symptoms of anorexia derive from these very evident struggles. The verbatim reports of the family interviews are fascinating and often instructive (although at times the therapeutic interventions seem rather coercive). They also demonstrate the skill of the principal therapists in assessing the dynamics of these dysfunctional families and intervening quickly to bring about behavioral changes that frequently are quite impressive. My own experience agrees with theirs on the significance of enmeshment. Typically, the relationship between these patients and their families is remarkably “sticky.” Treatment must address issues of overprotectiveness, intrusiveness, and control, as they are played out now; the patient needs help not only with her rebelliousness but also with the details of her entanglement in the family structure to reach individuation, autonomy, and identity. By making these points so sharply, the authors have clarified some of the key ingredients of effective treatment and made an important contribution. The other side, however, also stands out. Anorexia nervosa is presented strictly in terms of intrafamilial conflict. This view in its exclusivity seems as reductionistic as any of the earlier ones
that the authors deplore. A new specificity theory has been launched, but with scant recognition that the family characteristics here described do not lead necessarily to anorexia nervosa or to other psychosomatic disorders. Despite the emphasis on systems theory, the therapeutic prescription is, like the preceding ones, linear: instead of, say, interpreting unconscious fantasies, it tries to redress the power balance in the family. The outlook is narrow and this has other corollaries. No detailed histories of the patients are given and we are told very little about their emotional status. Psychiatric diagnosis is not mentioned beyond the fact that all the patients had anorexia nervosa. As for treatment, only the opening phase, which is heavily behavioral in orientation and aimed at getting the patient to eat, is described. Not much is said about the later phases or how they were conducted, although we are told that patients made progress in other ways than in their relation to food and that they successfully resolved major developmental tasks such as separating from their families, finishing school, making friends, and so forth. In summary, while the authors’ presentation is likely to strike the reader as rather one-sided, they have important things to say and they say them forcefully. The book will be appreciated mainly for what it offers to the treatment of this difficult and perplexing condition. As a theoretical formulation, Psychosomatic Families is least satisfactory and at times downright disappointing. It so happens that anorexia nervosa is studded with complexities, which this book often barely acknowledges. I’IETRO
CASTELNUOVO-TEDESCO,
M.D.
Vanderbilt University School of Medicine Nashville, Tennessee
as a Way of Life By J. W. Czaczkes and A. Kaplan De-Nour. New York: Brunneri Mazel, 1978 ($15.00) 235 pp.
Chronic Hemodialysis
Chronic hemodialysis can be considered paradigmatic of an emerging area of medical therapeutics that has rather unique characteristics. A certain disease, end stage renal failure in this case, would be rapidly fatal without treatment. The necessary medical regimen, however, involves a significant departure from traditional medical therapeutics. First, the treatment does nothing for the basic biologic pathology and thus is palliative, offering no hope of cure. Nonetheless, the regimen is very 277
Psychosomatic Families. Anorexia Nemosa in Context. By Salvador Minuchin, Bernice L. Rosman, and Lester Baker. Cambridge, Mass: Harvard University Press, 1978
Psychosomatic Families looks at anorexia nervosa from the vantage point of family therapy, which serves here both as a research tool and as a therapeutic modality. The authors are strongly convinced of the superiority of family therapy over other possible approaches, and this is the principal message of their presentation. The book is based on a study of 53 anorectic patients, most of them adolescent females, who were treated over a period of 7 years by 16 different therapists of varying levels of experience-senior psychiatrists, psychologists, social workers and psychiatric residents. Although over half of the patients were hospitalized initially, the authors believe that hospitalization should be avoided unless clearly mandated by the patient’s physical and emotional state. All the patients were treated first with family therapy, but some later received individual therapy as well. Pharmacotherapy played no significant role. In most cases, treatment was brief (several months); in a few instances, however, it lasted a year or longer. The authors achieved a very high rate of success. Of the 53 patients, 43 had a good outcome, 2 a fair outcome, and only 8 dropped out of treatment, relapsed or were unimproved. These results are considerably better than those of most other series, which report success in 40-60% of cases. The theoretical framework of Psychosomatic Families is that of systems theory. The locus of pathology is placed strictIy and squarely in the relationship between the identified patient and her family with its complex reverberating circuits of interpersonal pressures and counterpressures. The authors emphasize this bias by introducing the term 276
“anorectic family.” They are aware that this label is both unfelicitous and inaccurate, but they are so set on the view that the problem belongs with the family rather than with the identified patient, that they have chosen to stick with their term despite the objections inevitably to be raised. The principal characteristic of the “anorectic family” is “enmeshment.” This means that in the typical instance, there are insufficient boundaries both among the individual members and between generations. Intrusive and controlling parental behavior is the rule; the family is strongly child oriented, hypervigilant, overprotective, and controlling. These families are superficially harmonious; they deny interpersonal conflict and give loyalty and protection precedence over autonomy and self-realization. The future anorectic learns early to be compliant and good; anorexia thus becomes a logical battleground for struggles over control, autonomy, and individuation. Four cases are presented which focus on the therapists’ opening moves; their primary goal is to break up the power stalemate within the family which has permitted the patient to develop her anorexia to such dangerous proportions. A transcript of the first family session reveals the fundamental direction of treatment: to get the patient to eat and to redefine the problem as an interpersonal struggle centered on the issue of power. The approach is intensely active and deliberately confrontative, manipulative, and intrusive. The intent is not so much to clarify meanings as to change behavior, although in the course of these interactions, some important aspects of the non-eating behavior are inevitably clarified. The first behavior that USUally is addressed is the patient’s resolve not to eat. The therapist intervenes to upset the stalemate which supports the non-eating behavior, first by introducing himself into the previously closed system and then by lending his support and authority at different times to the various members of the General Hospital Psychiatry @ ElsevierNorthHolland,Inc., 1979
Book Reviews
family. The goal, ultimately, is to reduce enmeshment and stimulate the patient toward greater autonomy and self-realization. The authors see their own approach as innovative and radically different from earlier ones, of which they are often critical. In particular, they take exception with psychoanalytic and psychodynamic contributions. Psychoanalysts, they believe, have centered unduly on intrapsychic phenomena, and thus have emphasized irrelevancies instead of the real problem, namely, the often covert but powerful tensions between the patient and her family, in the present. The genetics of the patient’s difficulties, her fantasies, in fact her inner life are seen as of little moment. For the authors, the existence of a neurosis as a psychologic entity is overshadowed by the actual interpersonal struggles which, they feel, must be addressed directly if the patient’s condition is to be effectively treated. The issues raised here are complex and difficult to summarize in the brief space available; I will touch on only some major points. The book has very clear positives but also some insufficiencies that are equally apparent. Its strong suit is its forceful recognition of how family interactions influence and sustain the non-eating behavior. There are remarkably vivid portrayals of how patients behave in the context of their families and of how the symptoms of anorexia derive from these very evident struggles. The verbatim reports of the family interviews are fascinating and often instructive (although at times the therapeutic interventions seem rather coercive). They also demonstrate the skill of the principal therapists in assessing the dynamics of these dysfunctional families and intervening quickly to bring about behavioral changes that frequently are quite impressive. My own experience agrees with theirs on the significance of enmeshment. Typically, the relationship between these patients and their families is remarkably “sticky.” Treatment must address issues of overprotectiveness, intrusiveness, and control, as they are played out now; the patient needs help not only with her rebelliousness but also with the details of her entanglement in the family structure to reach individuation, autonomy, and identity. By making these points so sharply, the authors have clarified some of the key ingredients of effective treatment and made an important contribution. The other side, however, also stands out. Anorexia nervosa is presented strictly in terms of intrafamilial conflict. This view in its exclusivity seems as reductionistic as any of the earlier ones
that the authors deplore. A new specificity theory has been launched, but with scant recognition that the family characteristics here described do not lead necessarily to anorexia nervosa or to other psychosomatic disorders. Despite the emphasis on systems theory, the therapeutic prescription is, like the preceding ones, linear: instead of, say, interpreting unconscious fantasies, it tries to redress the power balance in the family. The outlook is narrow and this has other corollaries. No detailed histories of the patients are given and we are told very little about their emotional status. Psychiatric diagnosis is not mentioned beyond the fact that all the patients had anorexia nervosa. As for treatment, only the opening phase, which is heavily behavioral in orientation and aimed at getting the patient to eat, is described. Not much is said about the later phases or how they were conducted, although we are told that patients made progress in other ways than in their relation to food and that they successfully resolved major developmental tasks such as separating from their families, finishing school, making friends, and so forth. In summary, while the authors’ presentation is likely to strike the reader as rather one-sided, they have important things to say and they say them forcefully. The book will be appreciated mainly for what it offers to the treatment of this difficult and perplexing condition. As a theoretical formulation, Psychosomatic Families is least satisfactory and at times downright disappointing. It so happens that anorexia nervosa is studded with complexities, which this book often barely acknowledges. I’IETRO
CASTELNUOVO-TEDESCO,
M.D.
Vanderbilt University School of Medicine Nashville, Tennessee
as a Way of Life By J. W. Czaczkes and A. Kaplan De-Nour. New York: Brunneri Mazel, 1978 ($15.00) 235 pp.
Chronic Hemodialysis
Chronic hemodialysis can be considered paradigmatic of an emerging area of medical therapeutics that has rather unique characteristics. A certain disease, end stage renal failure in this case, would be rapidly fatal without treatment. The necessary medical regimen, however, involves a significant departure from traditional medical therapeutics. First, the treatment does nothing for the basic biologic pathology and thus is palliative, offering no hope of cure. Nonetheless, the regimen is very 277