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Unlocking the Mind’s Manacles

Selvini’s work offers an effective response to Elsa First’s ironic remarks at the expense of an “anthropological” approach. Her most brilliant book, Paradox and Counter Paradox,5 presents, among scores of others, the example of the young anorectic Mimma, who claims that her problem has to do with her fear of food poisoning. In general discussion with the family it emerges that to accommodate this fear her parents have transformed their kitchen into a sort of operating theater: all cutlery and utensils are sterilized and before sitting down to eat everybody puts on a white surgical coat, sterilized rubber gloves, and a surgeon’s cap. The therapist suggests that given this state of affairs Mimma is perhaps not the only unbalanced member of the family. There is a collective craziness at work here. This interpretation is immediately and vigorously denied by parents and siblings alike. Only Mimma is “crazy.” From a systemic point of view, however, Mimma, in line with the general search for power, is running the whole show and at the same time truly suffering more than anyone else.

Selvini’s undoubted success with anorectics6 led to her achieving almost guru status in the late Seventies, both in Italy and abroad. Very much in the tradition of Haley, she got her results by heaving a weighty therapeutic challenge into the tortured mechanisms of such families through a process of intuitive provocation and paradoxical prescription. “At what point”—a young anorectic might be asked after three or four sessions—“did it occur to you that by not eating you could finally show your lily-livered father how to bring Mother into line?” Or, at the end of another session a patient might be told that the therapists had come to the conclusion that her disorder was absolutely necessary for guaranteeing the equilibrium of the family and that until other changes occurred they could advise nothing better than that she continue to eat as little as possible. At this point the patient’s spirit of antagonism might be relied upon to function in her own interests rather than against them.

Having emerged, then, from a study of schizophrenia, the systemic approach was achieving its best results by creating a quite different disturbance. Significantly, however, when Selvini turned her attention away from anorexia to schizophrenia and attempted to satisfy Bateson’s hope that there would one day be an elaborate model describing the family relationships underlying the disorder, she could not repeat her success.

In Toward a Theory of Pathological Systems (1969), Jay Haley had sought to save the idea of the double bind by extending it to include three players in a so-called “perverse triangle,” this as a result of his observation that schizophrenics tended to be deeply involved in their parents’ relationships. In her book Family Games: General Models of Psychotic Processes in the Family,7 Selvini elaborated on this, painting a picture of stalled and embattled marriages where a child is drawn by one parent into a covert alliance against the other, only to realize at a moment of crisis that the favored parent is in fact exploiting him or her as a strategic element in the ongoing marital struggle. Not only is the child shocked and betrayed, but he also finds himself unable to protest, because the alliance itself is the source of feelings of guilt.

Selvini’s innovation here was to introduce the element of history into the systemic approach. Her portrayal of the anorectic’s family had been largely ahistoric, involving an ongoing, never-declared power struggle. Now, however, there was a precise series of events, a development that went some way toward countering the objection that the double bind did not explain why a symptom broke out at a particular moment. One could not appreciate how to alter a system of relationships and communication patterns, Selvini suggested, or what resistance such an attempt might provoke, until one understood what events underlay it.

As a method both of research and therapy, Selvini proposed that the therapist dismiss the children, including the schizophrenic patient, from therapy, see only the parents, and instruct them to announce to other family members that everything that happened in therapy was a secret they would not betray. After this they were to begin a series of unannounced evening disappearances designed to create the impression that a marital complicity had been reestablished.

The results of the approach were explosive. The frequency with which members of the family would complain that they were being excluded from the parental relationship, to the extent of calling the police because “he would never go out with her without telling me first,” convinced Selvini that the model she was developing was accurate. She also claimed dramatic improvements in patients whose parents had managed to put together at least a façade of complicity, thus liberating the child from the anxiety, excitement, and dilemmas of involvement in their parents’ relationship. Unfortunately, however, she could provide few statistics for lasting transformations. Even more crucially for the fate of her ideas, she made the mistake of describing these relationships in “the schizophrenic family” as “giochi sporchi” which, translated into English, produced the even more unfortunate-sounding “dirty games.” It seemed she was not only blaming the parents, but accusing them of callous indifference to the welfare of their children.

Family Games was published in 1989, but even before its appearance its preliminary presentation in 1986 was violently attacked by Carol Anderson in the pages of the Journal of Marital and Family Therapy. Anderson (who is now editor of the influential review Family Process) rightly took Selvini to task for her cavalier approach to documentation and statistics, but in the end her objections were more emotional than methodological. “I thought,” she wrote, “of the pain experienced by the families I’ve known as they struggled with their problems. How would they feel if they heard their desperate patterns of coping being described as ‘dirty games’?”

The position of outrage adopted by Anderson and others was testimony to a deep swing in opinion that no doubt went far beyond the borders of psychiatry and clinical psychology. However, in the particular field of family therapy her position consolidated a growing alliance with mainstream psychiatry which has always insisted, despite, it must be said, the absence to date of any conclusive results, that schizophrenia is mainly organic and genetic in nature.8 As Ugazio points out in her book, with regard to schizophrenia the systemic approach has encountered difficulties. It has also raised innumerable hackles. Even if Selvini was right in her analysis of the family systems surrounding schizophrenics (decades of literature on such families suggests she was not entirely wrong), nevertheless dealing successfully with their resistance to change was to prove far more difficult than it had been with the anorectic’s family and in any event far beyond the powers of a therapist with a few dramatic tricks up her sleeve. For a child who from earliest consciousness has been lured into a triangle in which the parents are perpetually at dagger’s point, it will be hard to believe that Mom and Dad have suddenly resolved their problems and chosen to exclude you. At a moment of psychotic crisis, tranquilizers and dopamine-blockers, though never a cure, are a more reassuring alternative than a long and perhaps agonizing reexamination of tangled relationships.

From this point on, then, family therapy largely threw in the towel when it came to schizophrenia. Or at least where such therapy is still used it seeks less and less to achieve a “cure” through a radical reorganization of a family’s way of communicating and concentrates instead on helping families live with a symptom to be treated primarily through drugs.9 “Often one has the impression,” wrote Selvini in her reply to Anderson, “that the times of Gregory Bateson and his colleagues are only a glorious memory.”

It is in the light of this defeat that Ugazio’s decision to exclude schizophrenia from her book must be understood. In reelaborating Bateson’s theories, as well as drawing on a huge range of reading in psychology and philosophy, she seems determined to give back to systemic therapy an intellectual dignity compromised by the many books that have told scarcely credible tales of dramatic cures, unsupported by theory or methodology. Basically, she seeks to produce an overwhelming combination of argument and evidence to demonstrate that the well-defined disorders she has chosen to discuss—phobias, obsessive compulsions, and anorexia—are indeed the result of the way sufferers have reacted to particular family situations. Her implication is that once we have established that ground, perhaps we can get back to “the stumbling stone for every psychological interpretation of mental illness,” schizophrenia.

The crucial innovation of Ugazio’s book is the way she combines Bateson’s theories of schismogenesis and the double bind. It is the schismogenetic manner in which character forms around semantic polarities in the family, she claims, that can, in special circumstances, place certain members rather than others in the position of intolerable dilemma known as the double bind.

Ugazio’s reformulation of the latter idea, designed to meet all the objections described above, is complex and draws heavily on the work of communication theorists V.E. Cronen, K.M. Johnson, and K.M. Lannamann.10 As well as insisting on the importance of the personal history of the eventual sufferer, Cronen and his colleagues suggested a certain ingenuousness in Bateson’s original formulation. It is not that one side of a given message is true but hidden (a mother’s antipathy) and the other false but apparent (her veneer of affection), but rather that the “social reality” of the eventual sufferer is constructed around a lifetime of contradictory but equally “true” (in the sense of sincerely meant) messages. In this scenario there is no question then of isolating a single message that would present a double bind for everybody. Context is all.

Let us return to the family that puts a high price on independence. This is the kind of family, Ugazio maintains, whose schismogenetic dynamics can lead to one member’s suffering from a phobia. How? We can imagine an adventurous, entrepreneurial father, frequently absent, a mother who assumes a “complementary” position, very much attached to her husband, admiring his spirit, but thinking of herself as at the other extreme of the independence/dependence polarity. A first son is encouraged to occupy a position symmetrical to the father’s and does so. He will compete for the palm of independence. The mother at once admires and is concerned, perhaps a little lonely. A second son becomes extremely attached to her. She finds consolation in his presence while never withdrawing her love and admiration from her husband and first son. As he becomes more conscious of the family situation, the second son senses that to win the kind of regard afforded to the others, he must be as radically independent of mother as they are. But in detaching himself from her he will lose the privileged position he has occupied to date and around which he has constructed his identity.

Without there being any single contradictory message, or anybody “behaving badly” in any way, an environment has been created where both the self-esteem of independence and the gratifications of attachment begin, at least for one member of the family, to seem at once absolutely desirable yet mutually exclusive. What life story can such a person construct for himself? Ugazio gives detailed case histories showing the kind of strategies a person who has grown up in such a situation will develop. Thirty-year-old Alberto has a proudly independent lifestyle counterbalanced by a series of superficial relationships which allow him to put off any serious emotional commitment. Elisa, on the contrary, has married an independent man, but has so successfully presented herself as fragile that despite his ambitions he has agreed to their living next door to her parents, where she remains very closely attached to her mother. Both of these patients can be seen to be occupying one side of the dependence/independence polarity while yearning for the other.

Ugazio describes the situations that may undermine such strategies and lead to the development of phobias. Alberto comes for therapy because he is no longer able to use an elevator and suffers severe panic attacks when he travels on planes. His claustrophobia developed shortly after his father died, and after his recent girlfriend dropped him. It is not, Ugazio remarks, the loss or new responsibility resulting from the father’s death that has led to the crisis, but the intense intimacy that was established with the father during his sickness. This, together with the loss of a girlfriend, is forcing Alberto to acknowledge an intense need for attachment; but for him to succumb to that need would bring an unacceptable loss of self-esteem. As he seeks to ignore and repress the issue, the claustrophobic symptoms, horror of enclosed spaces, and in particular those enclosed spaces he needs to use if he is to continue his independent life style become a powerful metaphorical reminder of his aversion to, and yet his need of, the tightly enclosed relationship. Though he has no plans to enter therapy with his family, Alberto chooses a systemic therapist because he feels that this will not involve the development of a close relationship of the variety associated with traditional psychoanalysis. Thus even while gritting his teeth and admitting a problem, he is simultaneously seeking to reinforce his independence. In the first session he demands to become like “a tower that will not fall.”

With a “strategy” diametrically opposed to Alberto’s, giving more importance to attachment yet yearning for independence, Elisa’s crises are agoraphobic rather than claustrophobic. They force her to stay at home. The first came as she stepped on board the cruise ship for her honeymoon and felt overwhelmed by panic. Ugazio remarks: “Going to Greece meant a decisive move away from the protective relationship with her mother…. Not to go meant damaging her marriage and the independence and self-esteem that went with it.” In her case, the ensuing mental disorder does not so much resolve the problem as remove it from discussion. Her husband will give up the cruise and many other adventurous projects over the decade before they enter therapy, not because Elisa isn’t genuinely enthusiastic and supportive, on the contrary, but because she is ill, she can’t go out.

While those suffering from phobias such as Elisa’s face a double bind that makes self-esteem and long-term attachment mutually exclusive, the obsessive-compulsive, in Ugazio’s model, has the more profound problem of being obliged to choose between opposite and equally unacceptable visions of self. Here the patient’s family constructs its conversation around the opposites sacrificial renunciation/ selfish indulgence. The sufferer is a child adopting a median position, not unlike the position Bateson occupied between his father and brother. A huge appetite for life, stimulated by those in the family occupying the selfish side of the polarity, makes a path of self-renunciation unbearable to contemplate. But the label of selfishness placed on almost any engagement with pleasure destroys self-esteem, which, for reasons of early attachment, largely depends on the judgment of someone occupying the renunciatory side of the polarity.

The classic symptoms of obsessive-compulsive behavior are of two kinds: compulsively repeated actions like washing hands or checking that a door has been locked (Ugazio recounts the case of a man who stopped his car every few hundred yards to see if he had run over a child or an animal). These may be seen as the neurotic reactions of one for whom every adventure into life generates guilt. The obsessions, on the other hand, take the form of the invasion of highly erotic or violent images over which the mind has no control. These can be seen as the repressed yearnings of one who is determinedly seeking self-esteem in renunciation and repression.

Again Ugazio offers examples suggesting how the condition can arise in particular family situations and the strategies developed to deal with it. Particularly intriguing is her account of the tendency to cultivate a hierarchical vision of “evil” which allows a “selfish” self to flourish just so long as it remains under the control of a superior “sacrificial” self. The case history of a hard-working priest living with his mother but allowing himself homosexual adventures in third world countries is instructive here. At age thirty, the priest had been hospitalized for two months with an acute obsessive-compulsive disorder involving extreme anxiety, intense, unwanted erotic images, and severe insomnia. After decades of relative health his symptoms recur when he is fifty-nine. Usually on return from his “holidays” his mother (decidedly on the renunciatory side of the critical polarity), though not privy to his secret, had been extremely severe in her attitude toward him, giving a welcome sense of punishment and facilitating his renewed acceptance of his “higher” self. But after the most recent trip the elderly lady was indulgent and spoke of “not always being there to look after him.” Suddenly the priest feels that the guarantee that his homosexuality will remain strictly circumscribed is gone. The conflict between selfishness and renunciation is renewed with, again, obsessive erotic images, insomnia, and anxiety as the result.

Ugazio makes it clear that her book is to be seen more as an analysis of the causes of the disorders she discusses than a manual of therapeutic approaches. She gives no prescriptions, makes no large claims. On the contrary she recognizes that by linking these disorders to the very process by which the patient’s character has been formed, her model demands that successful therapy achieve nothing less than a reconstruction of the patient’s way of experiencing and understanding the world, and in particular the world of relationships. All the same, and despite these sensible caveats, it seems only legitimate that the reader ask what hope her new systemic model offers for the sufferers she describes.

The issue of therapy is finally if rather unsatisfactorily addressed in the book’s last chapter. Ugazio clearly does not favor the dramatic forms of intervention proposed by Haley and Selvini. Nor does she take Bateson’s pessimistic line that such matters are too delicate to be interfered with at all. Rather she suggests that, having established the critical semantic polarity which dominates the patient’s life and within which he is unable to find a satisfactory position, the therapist can begin to look for other polarities around which the family of origin composed itself, since, as she insists, no family, however fierce the schismogenetic process, will be limited to just one polarity. Insofar, she claims, as she has alleviated and in many instances eliminated the symptoms of the patients described in the book, this has been achieved by gradually playing down the importance of the critical polarity and building on any others available in the patient’s experience to generate self-esteem in different ways and lead him or her to contemplate an entirely different life story. In this process, the original double bind does not so much disappear—after all, most of us are aware of, for example, a certain incompatibility between complete independence and close attachments—as become less urgent and all-determining.

In line with this approach, Ugazio concludes by remarking that one of the great dangers of therapy arises when therapist and patient concede the same importance to the same semantic polarity. Obsessive-compulsives, she claims, will tend to go to traditional Freudian analysts, because Freud himself saw the world in terms of indulgence and repression. This explains why, while offering such brilliant accounts of the disorder, Freud himself lamented his limited success in curing it. He could not move patients away from a vision he shared. Any inflexible approach to mental disturbance thus runs the risk of becoming, as Blake put it, another of man’s “mind forg’d manacles,” and may lead to situations where the therapist is actually exacerbating the patient’s difficulties. It is with this caveat that Ugazio ends her book by suggesting that “with respect to this [her own] as well as to other models of mental disturbance I believe the therapist must maintain a wise irreverence.”

The modesty here is exemplary, yet after the brilliance of her analysis of how double binds and illnesses can occur, one cannot help wishing that Ugazio had spent longer describing the process by which they can be eroded. And since various asides in Storie permesse indicate that she has worked with schizophrenics for many years, one likewise wishes that she had thrown caution to the winds and said more about possible uses of her model in dealing with that most intractable of disorders. All the same, the remarkable combination of imaginativeness and realism in Ugazio’s work raises expectations that she will venture further in the explorations that began when Gregory Bateson first arrived in New Guinea.

  1. 5

    Jason Aronson, 1978; originally published as Paradosso e contro paradosso (Milan: Feltrinelli, 1975).

  2. 6

    Selvini’s last book, Ragazze anoressiche e bulimiche (Milan: R. Cortina, 1998), includes a follow-up of patients dealt with twenty years ago, recording an impressive success rate. Those who worked with Selvini concur that she was a far greater therapist than writer, raising the problem how far one can rely on an “approach” and how much depends on the charisma of the practitioner.

  3. 7

    Norton, 1989.

  4. 8

    A recent publication in The New England Journal of Medicine suggests that the presence of a schizophrenic among family members increases one’s own chance of developing the condition by only 5 percent. Nor, given that one shares habits of communication with one’s family members, is that necessarily due to genetics. Living in the city rather than the country turns out to be a much greater danger statistically speaking, a factor that could point to either organic or social causes. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association mentions only behavioral, not organic, factors for diagnosing schizophrenia. Indeed the presence of organic alterations or pathologies which may be involved in the mental disorder explicitly excludesthe patient from being considered schizophrenic. There is no organic test or scan of any kind which can identify the presence of the disorder. With regard to a genetic component, the manual concludes laconically: “Although much evidence suggests the importance of genetic factors in the etiology of Schizophrenia, the existence of a substantial discordance rate in monozygotic twins also indicates the importance of environmental factors.” A study of the adopted children of schizophrenic and normal parents in Finland showed that the mental health of the adopting parents was at least as important as that of natural parents. Meantime, talk of such causes as an enlarged right ventricle of the brain and viral infections during fetal development is still largely speculative and no nearer to explaining the onset of the disease in late adolescence or early childhood than Bateson’s earliest formulation of the double bind. (See Christopher D. Frith, The Cognitive Neuropsychology of Schizophrenia, Lawrence Erlbaum, 1992). In short, this is a field where the consensus that has built up around what is now an orthodox point of view is disproportionate to the evidence actually produced. On its side, it must be said, the organic approach has the advantage that it does not lay the responsibility at anyone’s door while offering the hope that one day a miracle drug will simply cause the problem to disappear.

  5. 9

    Expressed Emotion in Families: Its Significance for Mental Illness, by Julian Leff and Christine Vaughn (Guilford Press, 1985), describes attempts to train families to deal with schizophrenics on their return from psychiatric institutions. These attempts mainly involve teaching family members to avoid expressing intense emotion and where possible even eye contact. The research published in the book shows that the rate of relapse is higher when a schizophrenic returns to his or her family of origin and highest when the return is to a mother living alone in a situation where both mother and schizophrenic are unemployed.

  6. 10

    V.E. Cronen, K.M. Johnson, and K.M. Lannamann, “Paradoxes, Double Binds and Reflexive Loops, an Alternative Theoretical Perspective,” Family Process, Vol. 20, pp. 91-112.

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