Hell and Back

by Tim Parks

  To complicate matters, a conflict had arisen between Bateson and Jay Haley, his most talented collaborator. Haley was a practical therapist and eager to use the ideas the project had been developing to get results. While Bateson would spend weeks chatting amiably to schizophrenics and taking notes, Haley wanted to save them, transform them. Bateson, however, was uneasy about his manipulative and invasive methods. The whole thrust of Bateson’s work had been that social behaviour is part of a delicate interacting ecology and that the mistake of traditional science was to believe that it could isolate areas of study and act upon them from a stable position without. However well meaning, intervention into something so complex as a schizophrenic’s family might feasibly make things worse. It is hardly surprising then that just as Haley’s hands-on manual Strategies of Psychotherapy appeared in 1963, Bateson abandoned the Palo Alto project to study patterns of communication among dolphins in the Virgin Islands. Nobody could reasonably expect him to change the lives of dolphins. His real goal in Palo Alto, he explained rather defensively, had never been therapy, but research.

  Valeria Ugazio does not disguise the fact that she came to Bateson not directly, but through the influence of her first mentor, the Milan-based psychotherapist, Mara Selvini. For precisely as the ‘systemic approach’ lost its intellectual father in the USA, it gained a new and charismatic champion in Italy. Selvini came to international notoriety with one of the earliest studies of anorexia, Self-Starvation, in later editions of which she offers a Batesonian model for “the anorexic family’: the disorder was to be seen, that is, as the result of a system of relationships and patterns of communication in the family.

  Basically, Selvini connected the rapid rise of anorexia to the process of transition which was then so radically altering the Italian family, eroding the old imperative of group solidarity in favour of a philosophy of self-realisation. The situation was particular disorienting, Selvini claimed, for women who, from being expected to sacrifice everything for husband and children, now saw themselves as potentially equal players on the family stage. The result, at least in the families she was dealing with, was a sort of covert, never-to-be resolved power struggle where each individual was chiefly bent on self-realisation but nevertheless obsessively determined, in deference to the old ethos, to disguise every personal initiative as a gesture of self-sacrifice. A typical discussion in therapy runs thus: Mother: “I have forbidden her [the patient] to wear miniskirts because I know her father doesn’t like them.’ Father: ‘I’ve always supported whatever my wife forbade the girls in my name. I felt it would be wrong to contradict her.’

  Ultimately, Selvini claimed, the contradictory desire to think of oneself as the person who has sacrificed most while in fact seeking to control everybody else could lead to a situation where authority is only acceptable when it springs from a pathology and is thus apparently beyond the individual will. Not for nothing, she claimed, does the refusal to eat combine an apparent gesture of self-sacrifice with a disorder that will demand attention and confer control as the family begins to function entirely in relation to the patient’s symptom.

  Systemic theorists never sought to explain the exact shift in the chemistry of the brain when a neurotic or psychotic symptom is first manifested (an achievement that has so far eluded the most advanced medical research), but rather to look for consistent patterns relating a disorder to the surrounding system of relationships. Thus, aside from the general transition across the social scene, Selvini concurred with other observers in finding that the families of anorexics tended to be characterised by an extremely strong mother complemented by chronically weak father (the dialogue above is again typical in this regard). In such a situation the sacrifice’ of not eating, a weapon directed far more at the mother than the father, could be justified by the anorexic at a subliminal level as an attempt to redress the balance of power, while in fact amounting to a determined attempt to take over the man’s role for herself.

  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 Counter Paradox presents, among scores of others, the example of the young anorexic, 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 theatre: all cutlery and utensils are sterilised and before sitting down to eat everybody puts on a white surgical coat, sterilised 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 ‘mad’. 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 anorexics led to her achieving almost guru status in the late seventies. Very much in the tradition of Haley, she got her results by heaving a weighty therapeutic spanner into the tortured mechanisms of such families through a process of intuitive provocation and paradoxical prescription. ‘At what point’ - a young anorexic 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 giving its best results with a quite different disturbance. Significantly, however, when Selvini turned her attention 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, Psychotic Games in the Family, 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 realise at a moment of crisis that the favoured 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 anorexic’s family had been largely ahistoric, an ongoing never-declared power struggle across the board. Now, however, there was a precise series of events, a development that went some way to 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, nor 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 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 which 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 w
ere 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.

  Psychotic Games in the Family was published in 1986, but even before its appearance its preliminary presentation was violently attacked by Carol Anderson on the pages of the Journal of Marital and Family Therapy. Anderson (who is presently 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 writes, ‘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 area of family therapy, her stance 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. As Ugazio points out in her book, with regard to schizophrenia the systemic approach had not proved to be an easy alternative. It had also raised innumerable hackles. Even if Selvini was right in her analysis of the family systems surrounding schizophrenics (decades of literature on such families suggest she was not entirely wrong), nevertheless, their resistance to change, unlike that of the anorexic’s family, went far beyond the powers of a therapist with a few spanners to throw. For a child who from earliest consciousness has been lured into a triangle in which the parents are perpetually at daggers drawn, it will be hard to believe that Mum and Dad have suddenly resolved their problems and chosen to exclude you. At a moment of psychotic crisis, the tranquillisers and dopamine blockers, though never a cure, are a more reassuring alternative than a long and perhaps agonising re-examination of tangled relationships.

  From this point on, then, family therapy largely threw in the towel in the area of schizophrenia. Or at least, where such therapy is still used, it seeks less and less to achieve a ‘cure’ through a radical reorganisation of a family’s way of communicating, and concentrates instead on helping families live with a symptom to be treated primarily through drugs. ‘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 Ugazios decision to exclude schizophrenia from her book must be understood. In recuperating and re-elaborating Batesons 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: 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 Ugazios book is the way she combines Batesons 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 that position of intolerable dilemma known as the double bind.

  Ugazios reformulation of the latter idea, designed to meet all the objections described above, is complex and draws heavily on the work of communications experts, Cronen, Johnson and Lannamann. As well as insisting on the importance of the personal history of the eventual sufferer, Cronen et al suggested a certain ingenuousness in Batesons 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, and with it the very epistemology 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 who put a high price on independence. This is the kind of family, Ugazio maintains, whose schismogenetic dynamics can lead to one member 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 polarity dependence/independence. 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 reaches a higher level of consciousness, 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 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 eventual patients can be seen to be occupying one side or the other 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 the death of his father, and his being dropped by a recent girlfriend. It is not, Ugazio remarks, the bereavement 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 unexpected 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, t
he claustrophobic symptoms, the horror of the enclosed space - and in particular those enclosed spaces he needs to use if he is to continue his independent lifestyle - become a powerful metaphorical reminder of his aversion to and yet 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 cruiser for her honeymoon. 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.