- 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.
Thechild,whoseEEGhadshownminimalbraindamage,wasbroughttofamilytherapywhenachildpsychoanalystrefusedtocontinuehistreatm
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