Psychosomatic FamiliesPsychosomatic FamiliesAnorexia Nervosa in ContextSalvador MinuchinBernice L. RosmanLester BakerWith a Contribution by Ronald LiebmanHARVARDUNIVERSITYPRESSCambridge, Massachusetts, and London, EnglandCopyright 1978 bythePresident andFellowsof HarvardCollegeAll rights reservedPrinted in the United States of AmericaThis book has been digitally reprinted. The contentremains identical to that of previous printings.Library of Congress Cataloging in Publication DataMinchin, Salvador.Psychosomatic families.Includes index.1. Anorexia nervosa. 2. Medicine, Psychosomatic.3. Family psychotherapy. I. Rosman, Bernice L.,joint author. II. Baker, Lester, joint author.III. Title.RC552.A5M56 616.8'5 78-1742ISBN 0-674-72220-5Tothe firstdiabetic childrenKaren, Patricia, and Deborahwho forced usto look at the critical role of thefamily in psychosomatic diseaseAcknowledgmentsThis bookis the endresult of tenyears of researchonfamilieswithpsychosomatic children, supportedby GrantsNIMH21336andNIHAM13518. Theresearchonthechildren whowerehospitalized intheClinical ResearchCenter of theChildren'sHos-pitalof Philadelphia as part ofthisstudy wassupported by GrantNIH RR240.The authors of the bookrepresent aninterdisciplinary team:psychiatrist, pediatrician, andpsychologist. Yet thecontributionsof theseindividuals representedfar morethanthe sumof theirareas of expertise. In the process of working together, we developeda system of differentiated but interdependent parts. The psychiatricinput wasenhanced bythe contribution of RonaldLiebman, M.D.,whowroteChapter 10andwasthetherapist for anumberofthecases followed in the outcome study. Thomas Todd, Ph.D., andLeroy Milman,M.D.,whocompletedtheteam,contributed greatlyto the development of ideas contained in the bool(.Many other colleagues, students, and teachers at the PhiladelphiaChild Guidance Clinic and the Clinical Research Center participatedin the treatment of the families and in the research meetings creat-ingtheatmosphereofcuriosity, excitement, andexplorationthatsustainedus throughthe difficulties of the project. Theyhelpedustocrystallize our ideas and encouraged usin their presentation.Amongthem, weowespecial thanks toLynnHoffman, whosug-gestedtheformat ofanalysis that was usedintheclinical chap-ters; GottliebGuntern, whoreadthemanuscript andgaveusefulsuggestions; PatriciaMinuchin, Ph.D., whohelpedwiththeorga-nization of the book and in other aspects of the writing; Fran Hitch-cock, whosecollaborationinthewritingandeditingwas invalu-viii / Acknowledgmentsable; Sherry Bell and Joyce Kobayashi, who carried out the follow-upstudy; and Marge Arnold, who patiently typed many draftsandredrafts of the book. We also want to thank Virginia LaPlante fromHarvard University Press for her contribution to the finished work.Anothergroupofpeople whocollaboratedinourbook, thoughanonymous, arethemost significant contributorsofall. Theyarethe familieswe studied, who endured our uncertainty and gropingand helped us to grow. To them go our warmest thanks.The transcripts of therapeutic interviews appearing inthisbookhave been edited to protect the privacy of the families involved. Thefamily interviews have alsobeenmade into trainingvideotapes,under the titles: IIPeople Take MyVoice," withcommentarybyLynnHoffman(Chapter8); IIRescueMission,"editedbyGottliebGuntern, M.D., withtheassistanceofGiovannaTodini, M.D., andDavid Heard, Ph.D. (Chapter 9); liThe Priestman Family"(Chapter10); and liThe Menotti Family"(Chapter 11). Information concern-ing these videotapesis available fromthe PhiladelphiaChild Guid-anceClinic, TwoChildren's Center, 34thandCivicCenter Boule-vard, Philadelphia, Pennsylvania 19104.Contents1 PerspectivesonAnorexiaNervosa 12 ThePsychosomaticFamily 233 The Anorectic Family 514 Blueprints for Therapy 745 Strategies forChange 926 The Opening Moves 1087 The Outcome 1268 The Kaplan Family 1399 The Gilbert Family 20410 The Priestman Family 24111 TheMenotti Family 28112 Psychotherapyfor a Small Planet 323AppendixA. TheFamilyTask 335AppendixB. ResearchinEndocrineAdaptation 338Notes 340Index 347Figures1. Linear modelof psychosomaticdisease 152. Opensystemsmodelof psychosomaticdisease 213. ChangesinFFAlevelsofanorecticchildrenduringfamilyintervievv 474. Medians of parent vvith higher FFA response and index patient 485. Individual vveight changes of eight anorecticpatients beforeand after lunch session 1236. Composite vveight changes of eight anorectic patients before andafterlunchsession 124Tables1. Behavior protocolduringhospitalizationof anorecticpatients 1152. Weight changes of eight anorecticpatientsfour days beforeand after lunch session 1253. Characteristics of fifty-three anorectic patients prior toparticipation infamilytherapy research program 1284. Treatment andfollovv-upoffifty-threeanorecticpatients 1295. Medical and psychosocial assessment of fifty anorectic patientsfollowingfamilytherapy 134Psychosomatic FamiliesPerspectives onAnorexia Nervosa1--------At the age of fourteen, Deborah Kaplan developed thesyndrome known as anorexia nervosa, or self-starvation. Typically,the illness seems to have begun when she decided to go on a diet inorder to pursue a career as a model. At firstshe followeda normalreducingdiet. But over aperiodofeighteenmonths shecut outmoreandmorefoods, until shewas eatingonlyapples, cottagecheese, andwater. Her weight droppedfrom110pounds to 78pounds, andamenorrheadeveloped. At thesametime, Deborah'sactivityincreased. Sometimes shewouldwakeupat four orfiveinthemorningandgoout towalkfor milesuntil it was timetoleave forschool. If confined to the house, she ran endlessly up anddown the stairs. She continued to be agood student, as she alwayshad been, butshe withdrew almost entirely fromthesocial activi-tiesofschool andsynagogue. Deborah'sparentsdescribedher asa good girl. They were proud of her grades and her behavior.Theycouldnot explainherrefusal toeat.Finally, on her pediatrician's recommendation, Deborah was hos-pitalizedinachildren'sfacilitythatwasresearchingfamilyinflu-encesonpsychosomaticsyndromesinchildren. Rigorousmedicalworkups ruled out the possibility of an organic cause for her refusalto eat, soDeborah and her family were referredtothepsychiatriccomponent of the team. The presenting problemwas anorexianervosa.Anorexia nervosa isapsychosomatic syndrome characterized bybothphysical andpsychological symptoms. It ispotentiallyfatal,with reported mortality rates of 10-15 percent. The disease usuallyappears in middle class females, the percentage of male anorecticsbeing very low. It generally starts during adolescence, though casescan also begin in preadolescence andin adulthood.12/ Psychosomatic FamiliesThereis somedebateinthemedical fieldconcerningtheexactcomponentsofthesyndrome. Inthisstudythediseaseis definedby both physical and psychological criteria. The physical symptomsinclude aloss of over 25 percent of the body weightas wellasoneor moreof the followingconditions: amenorrhea, hyperactivity,andhypothermia. Thepsychological symptomsincludea pursuitof thinness, fear of gaining weight, denial of hunger, distorted bodyimage, senseof ineffectiveness, andstrugglefor control.As is usual in our practic.e, the first session held at the psychiatricclinic with the Kaplan family was planned to incillde lunch.2Presentat the interviewwere Deborah, her parents, andher seventeen-year-oldbrother, Simon. WhenDeborahwas earlier negotiatingwiththe dietitian at the hospital, she had ordereda hotdog, peas,milk, andcottagecheese, tobesentover onatrayfor lunch. Thefamilyandthetherapist orderedsandwiches duringthe session.But when Deborah's tray arrived, she refused to eat. Consequently,the therapist instructed the parents to take over the task of gettingtheir daughter to eat while he was out of the room.MINUCHIN: I will be watching through the one-way mirror. I willcome back shortly. I want you to negotiate with Debbie. Otherwiseshewill die. Sheisstarving herselftodeath. I don'twant that tohappen. And she is your daughter. (Heexits.)MOTHER: Deborah, doyouwant tofinishthishalfofmysand-wich?It isverygood.DEBORAH: Dad, I toldyoulast night that I didn't likeit. But Itriedit.FATHER: Are you talking to me?Itold you that you aregoing tohavetoeat everything. Whenyouget uptoacertainweight, youcanpickyour ownshots, but right now, wearenegotiatingforyour survival, like Dr. Minuchin said. Your life. It is important thatyou eat.DEBORAH: Thedietitianwasuphere, andsheaskedmewhat Iwanted to eat.MOTHER: Youareoldenoughtounderstand. Dr. Minuchinwasjust inhere. And before youcametothehospital, I toldyouthatyou were going to die. Do you know what that means, Deborah? Youaregoingtodie! Youhaveabeautiful lifeaheadof you-youareonly fifteen! Deborah, thiscontains protein-FATHER: Deborah, how many doctorshave told you that you arePerspectives on Anorexia Nervosa / 3not adietitian? Now wipe out of your mind what those things con-tain, and just eat them.MOTHER: Let her finisheating. I thinkshe isgoingtotrytoeat.DEBORAH: I wastalkingtoareal dietitianhere. Shetoldmetoorder what I wanted. Andshesaidthat cottagecheeseis a verygoodsource of protein, andI don't haveto eatall that-MOTHER: Youhavebeenlosingweight ever sinceyouwent oncottagecheese andapples. Doesn't thatmeananything?You haveto start to gain. Do you understand what that means?You have toordermilkshakes, cakes, pies-DEBORAH: I don't like that stuff! I don't want it!FATHER: Yourlifeisinvolved, andyou havetoeat. Listen, Deb,don't graspontowhat adietitiansaysor what adoctor saysanduse that as an excuse. Tome, cottage cheese isaside order. Justadish-DEBORAH: Look at you.FATHER: What's wrongwithme? I weigh just what I shouldweigh. I wishtohellyoulookedlikeme. Deb, eat what'sonyourtray.DEBORAH: I don't like this!FATHER: But eat it.DEBORAH: No!No!I don't care. You carl shove it down my throat!I'llgetsick,andIwilldie.MOTHER: Well, whydidn't youorder somethingelsethen?An-otherkindof food?DEBORAH: BecauseI orderedcottagecheese! Andtheysaidtheywould give me meat three times a day, if I wanted it.FATHER: You have to eat meat three times aday.DEBORAH: No, no, no! Youknowa growinggirl eatswhat shewants. Oh, golly, you make me eat it!MOTHER: Anormal growinggirl eats certainnourishingfoods,and then she eats other things that she likes as well. You are starv-ing your body.DEBORAH: Iam not starving it! My pulse wentup. Everythingisgoing up.MOTHER: Then why are you losing weight? Over two pounds sinceyesterday, a half-poundthedaybeforethat. Youhavegot toeatmore. You have gottostarttogain, becauseyouaregoingtodie,Deborah! You won't have another chance. You have only onechance, right now.4 / Psychosomatic FamiliesDEBORAH: I won't die.MOTHER: You will.FATHER: Dr. Minuchinsaidtodayyoucanget out ofhereat 88pounds. I am not worried about that. Iknow that you are going toeat, and you are going to eat well, because if you want to get out ofthis hospital, you are going to eat. And you are going to put plentyof weight on. But the thing is this, Deborah. You are starting out onthe wrong foot, and you are acting wrong. I cannot understand thedifference in you between last night andthisafternoon. Last nightyoutoldme, IIDad, Iamgoing totry. Iam going toeat."MOTHER: Wait a minute, Abe.DEBORAH: I atethepeas insteadof apples. Andthis morningIaskedthem to bring me tea instead of milk.FATHER: But I toldyoulast night that whateveranybodygivesyou is not poison. It is food.It is not going to hurt you.DEBORAH: I can't eat that much! Youhavetoremember that Iam-MOTHER: Deborah, you don't have to eat that much. But eat foodthat will helptoput weight onyou. Youdon't evenhavetoeatthat muchof that, but certaintypesof foodarenecessary ...Inthisfamily, apatternrepeatsendlessly. Motherpleads, Deb-orah refuses, Father enters with afirmdemand, Mother intervenestosoftenFather's demand, Mother pleads, Deborahrefuses, andso on. Each repetition increases the intensity of the pleading, defy-ing, and demanding, but nothing is resolved. The pattern onlycontinues.Tothetherapist observingthesituation, it seemedthat when-ever the three family members came close to a decision, one of themwouldreact inawaythat deflectedconflict resolution, returningthetriadtothe staticrepetitionof anendless pattern. The par-ents, inparticular, seemedtonullifyeachother's efforts. Conse-quently, thetherapist re-enteredtheroomafterhalfanhourandasked the mother if she could help Deborah better alone.Mrs. Kap-lan nodded, so the therapist took Mr. Kaplan and hisson with himtotheobservation roombehindtheone-way mirror.MOTHER: Deborah, I wantyoutoeat. After youget your certainweight back, you can eat anything you want. Deborah.Deborah!Perspectives on Anorexia Nervosa / 5DEBORAH: Whydoesn't Dadget asandwich?Whydon't yougetone?MOTHER: Because Dad has enough meat on him, and he is not inthe hospital like you are. You are in the hospital, Deborah. You arehere forareason. You are here because youhave toeat. Youhaveto eat. There is no way out. Deborah, could you live if you stoppedbreathing?DEBORAH: Did I stop breathing?MOTHER: No, but you had better start eating. It is the same thingasbreathing. Ieat enough allday.DEBORAH: You don't eat the right foods!MOTHER: No, but I eat enough-I don't have toeat the rightfoods! Iamfullygrown. Inever leftapiece of food. HowcouldIeat and watch you starve? Hold your breath. See how long you canholdyourbreath. Foodislikeair! Youdidn't touchyourmilkoryourbeef.DEBORAH: Okay, Iwill finishthe beef. ButI'll get sick and vomitallover.MOTHER: I promise you, you won't get sick.DEBORAH: I don't want it! You force everything on me. EverythingI ever did!You have always forced me!MOTHER: Ihave never forcedyou. Deborah, fromdaytoday wedon't know whether you are going to survive. You are losing weightsorapidly. I mean, you are anintelligent girl. I don't see why youcan't reasonthisthing out. The only way togohomeistoeat.Letmesee youstart eatingagain, andsee how faryougo. Then we'lldiscuss it further.DEBORAH: No, no, no! I'll be defeated!MOTHER: Well then, be defeated. And I lost my appetite!Becauseyouhaveneverknownmetoleaveanything. Start eatingthehotdog now. You said you were going to. Go ahead.DEBORAH: No, no, no! After I finishthat, youwill startalloveragain. I don't want toeat anyofit! What didyoueatbeforeyoucame up here?MOTHER: I eat all day long, Deborah. I eat atremendous meal atdinner.DEBORAH: Coffee! Mints!MOTHER: I eatatremendousmeal! I'm notinthehospital. Youare. A.m I underweight, or are you? Yes,I should be in a hospital-6/ Psychosomatic Familiesamental institute, that'swhereI shouldbe. Becausethat'swhereyouaregoingtoput me! Nowgoaheadandeat. I said, goaheadand eat. Start wherever you want, and-DEBORAH: I am not going to finishit!MOTHER: Let's seehowfar yougo. Youknow, Deborah, I amdesperate. Do you know whatbeing desperateis?DEBORAH : Yes, I doknow.MOTI-IER: Supposeyouwereme, andIwereyou. Wouldyouletyour littlegirl starvetodeath?Wouldyou?DEBORAH: I wouldn't force her.MOTHER: If she were going to die, you wouldn't force her? If shewere going to die?DEBORAH: I-no!She wasn'tgoingtodie.MOTHER: Dh no, honey. You know she's going to die because she'snot eating. Youknowshe'sgoingtodie. Now whatwouldyoudoin that case? Would youfeedher, or let her do whatshe wants?DEBORAH: I wouldlet hereat vegetablesandprotein. Thisisn'tgoing tokill me.MOTHER: Whatkindof nonsenseisthat?You arestarving! Youare starving to death!Why do you think we are all here? This is nopicnic. Your father can't do any business. Your fatherislosing thebusiness! Doyouunderstandthat?Nowstart toeat, becausewemay not be sitting here tomorrow, because you'llbedead.Start toeat!DEBORAH: Idon't wantit!MOTHER: Start to eat now! Start to eat right now! (She is scream-ing.) Right now! Becauseeveryminutemeans somethingtoyou.To all of us. Start to eat, Deborah!DEBORAH (crying): I don't want it!MOTHER: You've gotto!DEBORAH: I don't wantit!Exhausted, Mrs. Kaplan burst into tears. The therapist, who hadcome back into the roomwith the other family members, sug-gested that she sit down and that Mr. Kaplan helpDeborah to eat.Thistime the therapist remained in the room.Mrs. Kaplancontin-uedtoweepsilently.FATHER: All right, Deborah. Now I'm not going to play any gameswith you. And I'm not going to leave this room unless they carry mePerspectives on Anorexia Nervosa / 7out bodily unless you finish everything that's on that tray. Now, youwantmylove. You wantto walkthedog withme. You're going-DEBORAH: I don't wantyourlove! I don't want anything.FATHER: Deborah, youcanthrowthathot dogonthefloor, butby thetimeI leavethisroom, you'regoing toeatthathot dog.DEBORAH: You can try, butIdon't want it!FATHER: Deborah, youcantalkall youwant, but-DEBORAH: I don't wanttotalk. Nowleavemealone! Youareal-ways making me do things I don't want to do. You always force me!FATHER: Deborah, listen to me. You say that I yell loud? You yelllouder than Ido. Now listen to me.DEBORAH: This is not going to get me anyplace.FATHER: Thisis going to get you plenty of places. But you're notgoing tobe abletodothingsyou wanttoinlife unlessyoufeel alittle better. Idon't wanttotalkabout therestof yourlife. Rightnow you'll finish what's on that tray. And I mean every morsel!Youunderstand? Because if you had a little more flesh on you, I'd beattheshit out ofyou! Doyouunderstandwhat you'vedonetothisfamily?Now you eat every goddamn thing that's on thattray! Andif you don't, you're not going to leave this room until you do. Nowstarteating! I'mgoingtogiveyouthreeminutestoeat it, andifyoudon'tstart, you'regoingtofinditinyourearsandyoureyesand down your mouth and everywhere else! Now you start eating!I'm not playing any games with you. Because we're pastthegame-playingstage. I lost mygoddamnbusinessandeverythingelse. Ilost my wife, and I lost my family because of you. And goddamn it,I'm not going to play any more games with you!Now you eat!Nowcome on. That's not poison.DEBORAH: Itispoison. Did youtryit?FATHER: All right.I'll eat alittle of it. (Hetakes a bite ofthe hotdog.) Now, isthispoison?DEBORAH: Itried it! (Shesobs hysterically.)FATHER: This is good food, and you eat it. Deborah, don't pull thatshit on me. Now eat it! If I thought it would kill you, I wouldn't letyoueat it. Don't you tell meabout cottage cheese andprotein.You're no goddamn doctor.Now eat it!Or you'll findmilk alloveryour hairandyour bodyandon your- (Still sobbing, Deborahtakesthe hot dog and crushes it.)Now I told you I'm going to giveyou a couple of minutes, and then I'm going to feed you myself. Be-causeeventuallyyou'regoingtoget fedwitha tube downyour8/ Psychosomatic Familiesstomach anyway. Look at your body, andlook atyourarms. Nowcome on, startto eat it. Starttoeat! And don't belikeatwo-year-old baby and make a big fuss out of eating a stupid hot dog. A lot ofkids wish to hell they had a hot dog for lunch.DEBORAH: Well, give ittothem!FATHER: I'm not going to give it to them, I'm giving it to you! AndI'm not wasting any food, either. Now Deborah, don't put meinapositionwhereI'mgoingtoget violent, goddamnit. Youeat thefood, or you're not going to see me in this goddamn hospitalagain.Idon't care if they carry you outof hereonastretcher. Nowyoueat it. Come on, eat the goddamn hot dog!Deborah, if you don't eatthishot dog, you'regoingtobesorry.DEBORAH: I don't want it! (She crumbles the mush in her hands.)FATHER: You eat it!Don't you destroy it, or I'll get you ten more.Now you eat it!DEBORAH: I don't want it! Look at it! It's ugly!FATHER: Eat that hotdog! I'm notleaving thisplace, I swear toGod, until you eat it. Eat it! And drink this milk. And eat the peas. Idon't mean leave it. Eat that hotdog! God damn you! You son of abitch!You eat the goddamn hot dog! I told you to eat it! (Hetakesthecrushedhot dogandshovesit intoDeborah's mouth. Shere-sists, and is smeared with food. Thetherapist intervenes,telling Mr.Kaplan to stop. Mr. Kaplan sits down, visibly exhausted andashamed of hisfailure.)These three members of the Kaplan family are all seriously trou-bled individuals. But when one watches the family together, it is thefutility of the triad's interactions that impresses the most. The fam-ilyrepeats stereotypedtransactions, nomatter howmanytimestheyproveineffective. Thereis noresolutionor closure, andnoescape. The Kaplans are trapped in aSisyphean pattern.Deborahdemonstrates thehopelessness andhelplessness com-mon to anorectics. "You force everything on me. Everything I everdid," she cries. Her refusal to eat the hot dog is a pathetic assertionof self against her conviction that she has always given in and thatshe willalways be madetogivein. Thisisaclassic component ofanorexianervosa.At thesametime, Deborahdisplaysanimpressiveabilitytore-sist her parents'combined and separate efforts. Sheseducestheminto peripheral issues with greatskill, and at timestakes on anal-Perspectives on Anorexia Nervosa / 9most parental stance herself. She feels helpless, but she is far frompowerless.Mrs.Kaplanis desperate. But she is equally incompetent.She isa woman who has devoted her life to being a good wife and motherin accordance with her values.But her futilereasoning, hermind-less repetition of ineffective interactions, and her inability to resistDeborah's red herrings all lend credence to her hints that she is partof the problem.The intensity of the father'sauthoritarianstatementsisimpres-sive. But so is their lack of effect. He presentsaclear demand, buthe always undercuts his own position by a long monolog that delaysthe necessity toact. If oneignoresthenoise,hispain becomesap-parent. But equally apparent is his inability to give a simplecommand.In thisfamily, Deborah islabeled theproblem. She suffers fromanorexia nervosa, and her illnessoccupies centerstage. IIIlost mygoddamned business and everything else. I lost my wife, andIlostmyfamily, becauseofyou,"thefather shouts. Tothefamily, allevents and transactions are intermingled with Deborah's terrifyingandmysterious refusal toeat. Theprofessionals concur, andthecase is labeled lIanorexia nervosa." But when these three membersof theKaplanfamilyare seentogether, anorexia nervosa seemsequally valid asadiagnosis of the familysystem.Our work with anorexia nervosa began as a search for more effec-tive modelsof treating psychosomaticillnessesinchildren. In thecourseoftenyearsofresearch, wehavebroadenedthescopeofbothdiagnosisandtherapybytakingthecurrent conflictsoftheanorecticandher familyintoaccount. Our paradigm, a systemsmodel, explores thepast influenceoffamilymembers onthede-velopment of symptoms. But it also explores the influence of familymembers on the maintenance of those symptoms in the present. Themodel delineates, andthereforeopens totherapeuticchange, as-pects of the family members' behavior that currently constrain theanorecticchildas wellasthe other familymembersand maintainthe anorexia syndrome.Linear and Systems FrameworksIn our study of anorexia nervosa, we found it useful to organize thevarious approachestodiagnosis and treatment of thisdisease into10/ Psychosomatic Familiestwomainconceptual models. Thefirst, whichwe call thelinearmodel, encompasses all the approaches that focus on the individualpatient: medical, psychodynamicandbehavioral. Thesecond, thesystemsmodel, buildsontheworkofthelinearapproaches, butgoesbeyond themtolook atthe patient incontext.Thelinearmodel has governedmost efforts tounderstandan-orexianervosa throughthe 300-year historyof the illness. Untilrecently, aninvestigatordescribingDeborahKaplan'scasewouldhave presented material relating only to her. The case report wouldhaveincludedthekindoffeelings sheexpressedintheinterviewsegment: hersense thatsheiscontrolled andhelpless, that sheisdependent and incompetent, and that her parents run her life. Theconflicts betweenDeborahandher parents might havebeende-scribed, but they would not have been deemed significant in therapy.Therapy wouldhavefocusedonDeborahalone.The linear approachto anorexia nervosa hasledto anumber ofvaluable insights into the inner life of the patient and her fantasiesaround food and eating. But it has alsoseriously restricted the ob-servation of thesyndrome. Diagnosis, andthereforetherapy, havetendedtozeroinontheindividual, totheexclusionof thecon-textual components of the anorexia syndrome. The result has beena treatment outcome that, even with the best practitioners, attainsa cure rate of no better than 70 percent, and seems to average a curerate of 40-60 percent.3The systems model analyzes the behavior and psychologicalmakeup of the individual by emphasizingthecontinuityofthein-fluencesthat family members have on each other fromthe earliestlifeofthechildthroughthepresentmoment. Thismodel affirmsthe significanceof the individual familymember's psychologicalexperience. The individual withinthe systemhas large areas ofautonomy where he or she transcends the system. But the systemsmodel also requires the observation of how and to what extent inter-personal transactions governeachfamilymember's rangeof be-havior. The systems model thus has a wider lens than the linear. Itlooks at the individual, but also at the individual in context. Treat-mentgoverned bythisconceptual modelhasprovento be86per-centeffectiveinthefifty-threecasesfollowedupoveraperiodofalmosteightyears.The history of the diagnosis and treatment of anorexia nervosa isoneof these evolvingmedical concepts. Approaches toanorexiaPerspectives on Anorexia Nervosa / 11havechangedinresponsetoageneral trendtoincludemoreandmore of the patient's context in the study and treatment of psycho-somatic illness-achangeinmental healthconceptsthat hasfol-lowedthesame generalshift in Westerncivilization'sconceptuali-zationofman. Inour time, wehavelearnedthat manis awarytraveler on Spaceship Earth, dependent on her dwindling resources.The study of man apart fromhis circumstances-man asa hero-is being replaced by a view of man as influenced by his context. Thischange can betraced inthe history of anorexia nervosa.The Medical ModelThe first identification of anorexia nervosaisgenerally credited toanEnglish physician, Richard Morton, who reported ontwocasesin1689. Hisclinicaldescriptionthenincludedamenorrhea, hyper-activity, and the loss of weight commonly regarded as componentsof the syndrome today:Mr.Duke's Daughter, in St. Mary-Axe, in the year1684, in theeighteenth year of her age ...fell into atotal suppression ofher Monthly Courses from a multitude of Cares and Passionsof her Mind. From which time her Appetite began to abate ...She wholly neglected the care of herself for two full years, tillat last being brought tothe last degree of Marasmus ... andthereupon subject to frequentFainting Fits, and apply'd her-selftomefor Advice.I do not remember that I did ever in all my practice see one,that was conversant with the Living so much wasted ... (likeaSkeleton only clad with skin).Mortontreatedthis patient withlIaromaticbags"appliedtothestomach, IIbitter medicines," and "antihysterick waters." Sheseemedtoimprove, IIbut beingquicklytiredwithMedicines, shebegged that the whole Affair might be committed againtoNature.Whereupon, consuming every day more, she was after three monthstaken with aFainting Fit, anddied."4Thecharacteristics notedbyMortonoccur againandagainindescriptionsof anorexianervosa. Two hundredyearslater, W. w.Gull presented asimilar picture:MissA., age 17, wasbrought tomein1866. Heremaciationwasvery great. Itwasstated thatshehadlost 36poundsinweight ... She had amenorrhea for nearly a year ... Slight con-12 / Psychosomatic Familiesstipation. Complete anorexia for animal food and almost com-plete anorexia foreverything else. Abdomen shrunk andflat,collapsed .. The condition was one of simple starvation ...Occasionallyfor aday ortwotheappetitewasvoracious,but this was rare and exceptional. The patient complained ofno pain, but wasrestless andactive. This wasinfact astrik-ing expression of the nervousstate, for it seemed hardly pos-sible that a body so wasted could undergo the exercise whichseemed agreeable. There was some peevishness of temper anda feeling of jealousy. No account could be given of the excitingcause.5E. C. Lasegue, who was working in France at aboutthe same time,described the syndrome in terms similar to Gull's.6 Both suggestedapsychological basisforthedisease, ashadMorton. Laseguecon-sidered it a hysterical phenomenon.Early investigators notedtheinfluence of the familyin anorexianervosa. J. Naudeau, writing in 1789, attributed an anorectic's deathtotheinfluenceof hermother.7Lasegue, describinganorectics in1873, observed: ItThis description ... would be incomplete withoutreference to their home life. Both the patient and her family form atightly knit whole, and we obtain a false picture of the disease if welimit our observation to the patientsalone."8These earlyinvestigators were medical men. TheyconsideredItnervousness" to be causative in anorexia nervosa, but they did notexplorethiscomponent, just astheydidnotexplorethepatient'scontext. Theypostulatedthat thepatient's bodywas respondingtounspecified psychological causes, andthey explored and treatedtheorganicresponseswithoutattemptingtodifferentiateortreatthepsychological causes.Eventodayinvestigatorsapplythesamemodel inthestudyofanorexia. Research into the possible etiologic role of cerebral, pitu-itary, and hypothalamic factorsisbeing conducted. Metabolic andhormonal changes seen in patients with anorexia nervosa are beingexplored. In these investigations, treatment programs are confinedtodrug therapy with amitriptyline,cyrporheptadine, dilantin, andL-dopa.9But the medical model, as Theodore Lidz pointedout,Itcould not encompass the interrelationship between mind andbody, or between the stresses of interpersonal relations and physio-logic activities. Psychiatry ...focused increasinglyuponman'sdevelopment as a social being, reluctantly abandoning animal mod-els toconcentrateonman'suniqueness amonganimals."loPerspectives on Anorexia Nervosa / 13The Psychodynamic ModelAnorexia nervosa was earlyrecognized as a psychosomatic syn-drome. In fact, according to E. Weiss and o. S. English, it was Honeof the clinical syndromes perhaps most responsiblefor bringingthe medical profession to believe that there may be a psychologicalbackgroundforcertainphysical diseases.11Un'dertheinfluenceofpsychiatry, particularly of Freud'sideas, inthetwentiethcentury,manyinvestigatorsinthefieldof psychosomaticmedicineshiftedfroma concernfor somaticmanifestations toa concernfor thepsychological underpinningsofthosemanifestations.Bythe1930s, theaimofpsychosomaticstudieswas toexplorethe interrelationships between the psychological and physiologicalaspects ofall bodilyfunctions andtointegratesomaticandpsy-chotherapy. The aimwas broad, but predictably, the field stillshowed a tendency to splinter along the lines drawn by its dual na-ture. Ontheonehand, therewas thetraditionofW. B. Cannon,later built uponbyH. SelyeandH. G. Wolff, whichemphasizedthe physiological concomitants of psychological states.12On theotherha11d, therewasthetendency, whichhasmorerelevancetoanorexiastudies, tofocus onthepsychiccomponents of psycho-somaticsyndromes.Psychodynamic investigators were interested primarily in thepsychodynamic profiles of patients with specific psychosomaticdiseases. Thechronological sequenceinwhichFreudianconceptswere givenspecific applicationtopsychosomatic diseasereflecteda widening inclusion of man's context in psychiatric thinking. H. F.Dunbar, having noted markedsimilarities in the personality traitsof patients with certain psychosomatic diseases, considered that thepersonalityprofiles derivedfromthosetraitsweretheimportantfactorintheetiology, prognosis, andtherapeuticapproachtothediseases.13Franz Alexander and hiscoworkers broadenedthisfor-mulationtoincludethreeotherfactors that theyconsideredetio-logic in specific psychosomatic diseases: organ systemvulnera-bility, geneticoracquired; psychological patternsof conflict anddefense; andthe immediate situation of theindividual atthetimeof thedevelopment of thedisease.14RoyR. Grinker went stillfur-ther, regardingthepatient asembeddedinhissocial context andemphasizing the need for a system orientation in exploring psycho-somatic syndromes.1514 / Psychosomatic FamiliesUnder the influence of the earlypsychodynamic thinking, thestudy of anorexia nervosa became the search foraspecific psycho-dynamicof theillness. W. PattersonBrownsuggestedthat thein-gestion of food symbolized impregnation.16J. V. Waller, R. M. Kauf-man, and F. Deutsch agreed that in anorexia IIpsychological factorshaveacertainspecific constellation centering aroundthesymboli-zation of pregnancy fantasiesinvolving the gastrointestinal tract."They were impressed by the 11 0 ft repeatedpatternof emphasisonfood, alternate over and under eating."The alternation of overeat-ing withdisgust for food represented to them a shift in the dynamicconflict. Inthefirst instance, theimpregnationfantasywasgrati-fied. In the second, the ensuing guilt and anxiety forbadthe intakeof food. The amenorrhea and constipation of anorexia nervosawerealsoviewedasreflectingthepregnancyfantasy.17Foratime,psychodynamic theory tookprecedenceover empiri-cal findings. Casesexhibitingtheclassicsymptomsof anorexia-lossofweight, lackofappetite, amenorrhea, andhyperactivity-were not considered anorexia if the psychodynamics of the case didnot fit theschema. A presentationbyJ. H. Massermanwas chal-lenged because his descriptions of the dynamics of the case did notinclude pregnancy fantasies.18The specificity theory was becomingaProcrustean bed.Eventuallythe theoryof a one-to-onecorrelationbetweenthepsychodynamic and the psychosomatic was challenged even inpsychoanalytic circles, and more varied explanations appeared.Helmut Thoma described the case of Henrietta A.,anineteen-year-old secondary school girl, who was admitted to the hospital with adiagnosisof anorexia nervosaandunderwent 289sessionsof psy-choanalysis spread over two years:Torn between her inability to be a boy and her dislike of beinga girl, she bolstered up her confidence with a new ideal of sex-uality ... By denying tldangerous" aspects of the outside worldand by repressing herdrives, thepatienteventually attainedastateoftheegothatwasfreefromanxiety ...In the anorexia itself, the following psychogenetic processesare discernible. (a) avoidance of realistic drive satisfac-tion. (b) the fending off of receptivity (tlsomethingcomesintome") because the unconscious is linkingnourishmentwith impregnation. Revulsion and vomiting are related to thesexual defense. (c) oral satisfaction is connected uncon-sciously with destruction and killing. Therefore, eating isrestrictedoris fraught withguilt.19Perspectives on Anorexia Nervosa / 15For E.I. Falstein, S. C. Feinstein, and I. Judasthe possible psycho-dynamicsourcesof anorexia hadbecomealmostunlimited: IIEat-ingmaybeequatedwithgratification, impregnation, intercourse,performance, growing, castrating, destroying, engulfing, killing,cannibalism. Foodmaysymbolizethebreast, thegenitals, feces,poison, a parent, or asibling."20As psychosomaticstudiespulledawayfromthespecificitythe-ory, it became possible to bring more of the components of anorexiaand of the patient's context into the field of observation. In fact, allmodels of investigationwererespondingtothechangeinworldview thatsaw man increasingly asanacting andreacting memberof asocial context. More and more, the patient's context was beingincluded asasignificant variable in concepts of psychosomaticill-ness. Thelocus of pathology, however, was still describedas in-ternal. IIExternal"stresseswereseenasimpingingupontheindi-vidual, and the individual remained the focus of diagnosis andtreatment.By the1950sthe varioustrendsinpsychosomaticmedicine hadmerged into a conceptual model that linked together the three com-ponents of stress, emotion, and illnesses in a linear, causal relation-ship (fig. 1 This model is like a large funnel. Many factors are rec-ognized assignificantintheexploration andtreatmentof psycho-Otherphysiological andbiochemicalsystemsAutonomicnervoussystemLife stresses .Personality Defenses and coping

EndocrinesystemDiseaseFigure 1. Linear model of psychosomatic disease.16 / Psychosomatic Familiessomatic disease, but ultimately they all converge on the individual,who is presumed to be the passive target of their effects.Much research wasfocused on fleshing outthismodel. Sophisti-cated studies were made onthemechanismsby whichthephysio-logical mediatingsystems wereinvolved indisease, ondifferentia-tionof thevarious kinds of life stress, andonthe relevance ofpersonality profiles and psychodynamic patterns. However, the im-pact of this research was disappointing.Clinical psychosomatic re-search had not kept pace with developments in other fields of medi-cine, Engel charged, andexperts inpsychosomaticmedicinehadfailedtodeliver much more than platitudes andlargely untestablehypo,theses. Inparticular, hepointedout, theimpactofincreasedunderstandinghadnot beenreflectedbymoreeffectivemethodsof therapy.22Thelinearmodel itself wasincreasinglyquestioned. Engel spe-cifically rejected the linear concept of psychosomatic etiology,arguing thatthepathogenesisofdiseaseinvolvedaseriesof nega-tiveandpositivefeedbacks.23I. A. Mirskydefinedpsychosomaticmedicine as an approach to man which emphasizes that Ilevery levelof organization, fromthe social to the molecular,is involved in thepredisposition, and precipitation andthe perpetuation of thevari-ous clinical derangements that plague man in his society."24 Grinkertoocalledfor a broader viewpoint: lilt has become thecontem-porarytaskof biological science, advancedbytheborrowingoffieldtheory fromphysics, tostudy integrationinamoresophisti-catedmanner than as a simple relationship betweenparts ...Oftenthepsychosomaticfieldhasbeensharplybrokenintofrag-ments ... [But]today we have come to realize that both the geneticandthetransactionalapproachrequirefor analysisandsynthesisthe concepts of afieldtheory.25HildeBruch, oneoftheforemost investigatorsofanorexianer-vosa, alsocalledfor amorecomprehensiveframeworkfor study:IIPascinating as it [is]to unravel the unconscious symbolic motiva-tion, thewhyofthedisturbedeatingpatterns, thegreat diversityitself [suggests]the question of how it has been possible for a bodyfunctionas essential and basic asfoodintaketodevelopin suchaway that itcould be misusedso widely intheserviceofnonnutri-tional needs."26 In attempting to devise a broader framework,Bruch hypothesized that something had gone wrong intheanorec-ticpatient'searlyexperiential andinterpersonal processes, warp-Perspectives on Anorexia Nervosa / 17ing her ability to identify hunger correctly and todistinguish hun-ger fromother states ofbodilyneedor emotional arousal. Morespecifically, ilif confirmation and reinforcement of his own initiallyrather undifferentiatedneeds andimpulses havebeenabsent, orhavebeencontradictoryorinaccurate, thenachildwill growupperplexed when trying to differentiate between disturbances inhis biological fieldandemotional andinterpersonal experiences,and he will be aptto misinterpret deformities in hisself-body con-cept asexternallyinduced. Thushewill becomeanindividual de-ficient in his sense of separateness, with diffuse ego boundaries, andwill feel helpless under the influence of external forces."27Bruch'sworkisaseriousattempt toencompassthecontextualcomponentsof anorexia,whichhavebeenacknowledgedbymanyinvestigators. But theboundaries ofher explorationarestill de-terminedbythelinearparadigm. Althoughsheexplorestheinter..personal, chieflytheinteractions betweenthemother andchild,her focus remains on the past, and on the internalization of thein-terpersonal as anintrapsychicphenomenon. The interactions ofpatient and family in the here and now are still outside the focus.Consider Bruch's report of a patient called Gail, who was twenty-one and had been under psychiatric treatment for anorexia nervosafor nearly ten years:Her absolute insistence on remaining atthis magic weight of96 pounds led to her dominating the household with enforcedrituals. Her parents were forced to shop three times aday be-cause she would not permit food in the home between meals.Any foodleft over after ameal hadto be thrown away, sinceshe fearedthatshe mightsuccumbtothe compulsion of eat-ing it and thereby spoil her magic weight ... In order to study,she had to have absolute quiet around the home and her par-ents were not allowed to be there when she worked ... Afteroneof herhospitalizationsherbehaviorwas soviolent thatherparents movedout intoa furnished room, theaddressof whichtheykept a strict secret [fromGail] ...It wasarrangedthat Gail andherparentswouldnot communicatedirectly, but that all messageswouldgothroughthesocialworker, who wouldalsosee the parentsregularly.28Gail's tragedywasnot anindividual matter. It was a tragedyin-volving at least three people, interacting in the present, victimizingand being victimized, enmeshing and seeking escape. However, thediagnosis over tenyearsoftreatment was still individual. Conse-18 / Psychosomatic Familiesquently, thetreatment ofchoice wasindividual therapy, achoiceresulting in years of enormous stress for Gail, her parents, and un-doubtedlythetherapistsaswell.The same restrictive organizationof data affects the work ofmany otherinvestigators whoobservedtheir patients' familycon-textsandreportedonthefamily'sinfluenceonthesyndromeandthe syndrome's impact on the family.29They describedthe precipi-tating factorsof anorexia nervosa in familyterms, such as maritalconflict, the return of a long-absent parent, or a death in the family.Nevertheless, the main thrust of their etiological investigation wasto search for the fantasies connected with eating disturbance. Hereagain, theindividual frameworkcreateda Procrusteanbed. Cur-rent conflictsinthefamily, thoughwell observedandclearlyde-scribed, were still presented as recurrences of conflicts in thepatients' early childhood. The ongoing influence of current circum-stancesstayedoutsidethefocus. Whereaspsychodynamicallyori-ented investigators consistently described anorexia nervosa in termsthat should have logically directed their attention to the family con-text, theycontinuedtodeal withtheindividualpatientalone.The Behavioral ModelIn the history of anorexia nervosa, the medical and psychodynamicmodelshave been the two major linear governing concepts. In thepast decade, a third approach, operant conditioning, has beenadded to this conceptualization and treatment of anorexia. Be-havioristsinterpretthepatient'scontextasaset ofcontingenciesthatneedto be controlled.In contrast to psychodynamic investigators, behavioral theoristsare much less interested in the origins of processes than in thede-velopment of instrumentalities for changingthose processes. AsLeonardP. Ullmanexplained, lithebehavioral therapist looks atwhat people are doing, not why they are doing it, in order to designa programthat will reinforce behavioral change andextinguishpathological behavior." To the behavioral therapist, Ullman furtherremarked: lI a person's difficulty is his behavior in reaction to situa-tions, and ...thisbehavioristheresult ofpreviousandcurrentreinforcing stimuli andisnotsymptomatic of some deeper under-lying discontinuitywithnormal functioning that must be dealtwith prior to the emitted behavior ... In evaluating a situation, thePerspectives on Anorexia Nervosa / 19behaviortherapist must shift fromthetraditional whyquestionsto what questions. He must ask: Whatisthe persondoing?Underwhatconditionsarethesebehaviorsemitted? ...What otherbe-haviorsmightthe person JohnPaul BradyandWolframRieger, whenusingbehavioraltherapyinthetreatment ofanorectics, approachedthesyndromeas an eating phobia: HEating generates anxiety, and their failure toeat represents avoidance. Inotherwords ...cessationofeatingafter ingesting a very small portion of a meal (or removing it fromthe body by self-induced vomiting) isreinforced by anxietyreduc-tion. Fromsuch an analysis, two treatment procedures suggestthemselves: deconditioning the anxiety associated with eating,and/ or shaping eating behavior ... by making accesstopowerfulreinforcerscontingent on Suchaprecise, clearanalysismakes it possible forthe behaviorist to create amilieu for the hos-pitalized patient in which appropriate contingencies are developed.Becausethehospital context canbecontrolled, behavior inthisenvironmentcanbechanged.Unfortunately, the focuson the individual'sdysfunctionallearn-ing has handicapped the behavioral therapist in drawing appropri-ateconclusionsfromhisowndata. Oncethepatienthasachievedthe desired weight gain in the hospital, she is commonly returned toherunchangedenvironment,whichof courseisnot controlled bythebehavioral therapist. It isnot surprising, therefore, that inalargepercentageofcases theimprovement is not sustainedafterthe patient has been discharged from the hospital.Onlythebarest outlineof thehistoryof anorexianervosahasbeenpresentedhere. Thereare cases inthe literaturereportingcures by the use of methods ranging from frontal lobotomy tocon-versiontoC11ristianScience. But most of themethods reportedeffective in some caseshave been reportedineffective in others. Inmany reports, it is impossible to derive even an estimate of results.Whereresultsaregiven, thesuccessrateattainsalevel nohigherthan70 percent.In any other field, such a disappointing outcome would certainlycall the procedures used into question. Unfortunately, investigatorsofanorexianervosahavedemonstrated, toastartlingdegree, theblindersimposed onthescientist by hisconceptualmodel. Practi-tioners maintain their previously learned paradigms as though theywere causes to be defended, not hypotheses to be tested.20 / Psychosomatic FamiliesThomas S. Kuhn, inexaminingthis tendencyofresearchers toclingtoexistingmodelsandtoresist change, contendedthat thescientist's visionis severelyrestrictedbecause, litoanextent un-paralleledinmost fields, theyhaveundergonesimilareducationsand professional initiations; in the processthey have absorbed thesame technical literature and drawn many of the same lessons fromit. Usually the boundaries of that standard literature mark the lim-its of ascientific subject matter." Much of the success of thescien-tificcommunityinfact derivesfromitswillingness todefenditsshared assumptions-or"normal science,"inKuhn'sterminology-"if necessary atconsiderablecost. Normal science, forexample,often suppresses fundamental novelties because they are neces-sarilysubversiveofitsbasiccommitments."But, Kuhnsuggests,whentheprofession" cannolongerevadeanomaliesthat subvertthe existing tradition of scientific practice-then begin the extraor-dinaryinvestigationsthat leadtheprofessionat last toanewsetof commitments, a new basis for the practice of His for-mulationbearsconsiderablerelevancetothehistoryofanorexianervosa.The Systems ModelToday, many investigators are beginning to include in their formu-lationstheinterdependenceof partsinasocial context. Thegov-erningframeworkfor their approachis thesystems model. Thismodel positsacircularmovement ofpartsthat affect eachother(fig. 2). The system can be activated atany number of points,andfeedbackmechanisms are operative at many points. The activationandregulationofthesystemcanbedonebysystemmembersorbyforcesoutsidethesystem.Inthe linear model, thebehavior of the individual is seenassparkedbyothers. It presumesanactionanda reaction, a stim-ulusandaresponse, or acause and aneffect. Inthesystems para-digm, every part of asystemisseenasorganizing andbeingorga-nizedbyother parts. Anindividual's behavior is simultaneouslyboth caused and causative. A beginning or an end aredefined onlybyarbitraryframingandpunctuating. Theactionof onepart is,simultaneously, the interrelationshipof other partsof thesystem.Thesystemsmodelpostulatesthatcertaintypesof familyorga-nizationarecloselyrelatedtothedevelopment andmaintenancePerspectives on Anorexia Nervosa / 21\Extrafamilial Familystresses organizationandfunctioningVulnerablechildSymptomaticchildPhysiological,endocrine, andbiochemicalmediating mechanismsFigure2. Opensystemsmodel ofpsychosomatic disease.ofpsychosomaticsyndromesinchildren, andthat thechild'spsy-chosomatic symptomsin turnplay an importantroleinmaintain-ing the family homeostasis. Anorexia nervosa is defined not only bythebehavior of onefamilymember, butalsobytheinterrelation-ship of all familymembers.Thismodel challengesoureverydayexperience. Weall tendtoexperience ourselves as the unit of our lives. When psychiatry,therefore, deals withtransactions amongpeopleas introjects inthe individual's experience, it is merelyvalidating the commonreality. The systems modeldemandsaquantum jump: acceptancethatdependency and control, attraction andaggression, symbiosisand avoidance, are more than introjects. They are interpersonal in-teractions inthepresent. Thepsychological unit is not theindi-vidual. I t istheindividual inhissignificant social contexts.Nowhere is the truth of this modern challenge demonstrated moreclearly than in the studies of psychosomatic medicine. Itseemstoviolatecommonsensethat thecontractionof achild'sbronchioleis regulated by sequences of transaction between other family mem-bers. Or that a diabetic patient's ketoacidosis is affected by the wayhis parents request his allegiance. Or that an anorectic's not eatingis controlled by the way the anorectic and her parents transact theissuesofcontrol. Nevertheless, ourfindings clearlyindicatethat,when significant family interactional patterns are changed, sig-nificant changes in the symptoms of psychosomatic illness alsooccur.22 / Psychosomatic FamiliesThechangetoa systemsparadigmresults ina different obser-vational frame. Insteadof observingandstudyingthe anorecticchild alone, we look at the feedbackprocesses by vvhich the familymembers and the anorectic constrainand regulate each other'sbehavior. Intherapy, we lookat the transactions amongfamilymembers that sustainthe anorectic syndrome, andwework tochangethosetransactions. Anorexianervosabecomes morethanDeborah's not eating. It isthe way the Kaplan familybehaves.The Psychosomatic Family2-------Mental health practitionersdo not, asarule, deal with is-sues of life and death. If a patient suffers a psychotic breakdown, orif there are bickering and unhappiness in a family, the therapist cantake his time in unraveling these mysteries of life. But when a thera-pist deals with a seriously disturbed psychosomatic patient, he sud-denlyentersamoredramaticarena. Thepsychosomaticdiabetic,the severely asthmatic child, or the cachectic anorectic are childrenwhose lives are in danger.We were drawn into the fieldof psychosomatic medicine, not byany fixed philosophical bent, but by the severity of the clinical prob-lems posed by patients who came under our care. Like many otherprojects in psychosomatic medicine, ours grew out of a disappoint-ment with the therapeutic results of individually oriented ap-proaches. New ideasinthe mental healthfield, highlighted by ourownobservations, encouraged ustobroaden ourfocus toincludeextraindividual components of thepsychosomaticprocess whichhad always been peripheral to the individual concept frameworks.Early Explorations on DiabetesThe patients who first forced us to question the methods forstudy-ingandtreatingtherelationshipbetweenpsycheandsomawerediabeticchildren whohad undergone unusuallynumeroushospit-alizationsfor diabeticacidosis. Suchhospitalizationshouldbeaninfrequent occurrence in a diabetic child's life. Acidosis may be oneoftheinitial, presentingsymptomsinachild withpreviouslyun-diagnoseddiabetes. But itisrare for adiabeticchildtoberehos-pitalized foracidosisonce treatment hasbegun, primarily because24 / Psychosomatic Familiesthe child and the family, after having learned to recognize the earlywarningsignals for impendingacidosis, cantreat it correctlyathomebyadministeringsupplemental doses of insulin. Repeatedbouts of diabetic acidosisarethereforedistinctly unusualandaregenerally thought to be avoidable.But unlikechildrenwithunormal"diabetes, thesechildrendidnot respond asexpected toan optimal medicalregimen. They con-tinued to suffer frommedically inexplicable attacks of acidosis. Asaresult,they were virtually crippled by theirdisease, requiringre-peated hospitalizations-as often astentofifteentimes per year-tocorrect life-threateningdiabeticacidosis. Theinitial approachtothesechildrenwas tohospitalizethemoncemoreinorder toevaluate thoroughly any organic factorsthatmight beresponsiblefor therepeatedboutsofacidosis, toreeducatethechildandthefamilyin acting early topreventdiabeticacidosis, andtolookforany other complicating factors. Thechildren wereplacedon whatwas considered an optimal diabetic regimen, which would preventrepeated hospitalizations.During this hospitalization no complicating organic factors werefoundthatmightexplaintherepeatedboutsofacidosis. TIlechil-dren and their parents were given intensive diabetic education. Thepediatric team was therefore taken aback when, followingthechil-dren'sdischarge, the previous pattern of hospitalization persisted.This outcome was particularly striking because these children hadbeeneasytotakecareofwhileinthehospital andtheir diabeticcontrol hadbeenexcellent.Because of the fortuitousreferral of three diabeticgirlsin closesuccession, it seemed that there was always one girl in the hospitalrecoveringfromacidosis, oneonthewaytotheemergencyroomfor treatment, andoneonthetelephonereportingthat things athome were sliding inexorably downhill. The most baffling aspect oftheir cases was the repeated observation that these children did notrespondasexpectedtoinsulinadministeredat home. Oneofthegirls,whosedailyinsulinrequirementwas30Llnits, receivedover500 unitsof insulin at home within an eighteen-hourspan. Thein-sulin, which had been administered to the child by the mother, waslater checked and found to have full biologic potency. Nevertheless,the child still had to be admitted to the hospital because of diabeticacidosis. Inthehospital, followingcorrectionof heracidosis, sheonce again required only 30 units of insulin toachieve satisfactorycontrol of herdiabetes.The Psychosomatic Family / 25Thethreegirlsweremuchalike. All wereinearlyadolescenceand appeared quiet, gentle, and pleasant. They were model patients,oftenhelpingthenurses tocarefor theyounger childrenonthewards. Their families appeared stable, helpful, concerned, andeagertofollowinstructions. Inthetraditionalmedical model, theabsenceoforganicfactors suggestedthat thedisorderbeconsid-ered functional, or of psychogenicorigin. Psychiatric consultationwas therefore obtained, and the children were entered into therapy.Althoughdifferent individuallyorientedpsychiatrists saweachchild, thepsychiatricformulations of theproblems ineachcaseweresimilar: the patientshaddifficultyinhandlingUstress,"theytendedto internalizeanger, andthey weresomewhat immatureintheirabilitytocopewithdifficult situations. It thereforeseemedthat these children had a major psychosomatic component to theirdiseaseinthemost literal sense, that is, anemotional arousal oftheir psyche causally and directly led to adecompensation of theirdiabetic state. While it was clear that emotions were not the causeof the diabetes, it wasbecoming more and more evident thatemo-tionsand emotional arousal were thekey tothe repeated boutsofacidosis.The girls were begun on individual psychotherapy orientedtowarddefiningpersonalityissuesandreducing"stressfactors."The families were involved only in the sense thatthey were told tobe extremelygentle intheir handlingof the childrenandtobecareful not to add any furtherstress at home.Buttheweeklytherapysessionshadnoobviousimpact onthehospitalizationpatterns, for theboutsofacidosiscontinued. Con-sequently, thechildrenweresent toanintermediatecarefacilityassociatedwiththeacutecarehospital, whereindividual therapysessions were continued. Again, no problems withdiabetic controlwereencounteredwhilethechildrenwereinstitutionalized. Thisresult wasviewed ascorroboration of the formulationwhich heldthat these children had a low threshold of response to stress.The therapeutic endeavors at this time were shaped by the linearmodel ofpsychosomaticdisease. Thechild wasviewedasa u con-tainer and carrier" of the disease. External stresses and the child'spersonalityprofilewereviewedas thekeyfactors. Consequently,aneffortwasmadetotreat thepatientonanindividual basis, inorder tomake her understand and express her emotionsmoreap-propriately and to help her acquire better coping capacities. Someattempt wasalso madetoreduce externalstressful situations.26 / Psychosomatic FamiliesThe importance of the family wasrecognized, but only inanon-specificmanner. Thestrikingdifferencebetweentheeaseof dia-betic control inthe hospital andtheimpossibility of diabeticcon-trol in the home led to the conclusion that the familyenvironmentwassomehow noxious. The child wasviewed asthe passiverecipi-ent of external stress-a victimof her environment. Theresultingtherapeuticdecisionwas toseparatethechildfromthefamily-to perform, in the old phraseology, a itparentectomy." In eachcase, theboutsofketoacidosisreappearedwhenthechild wasre-turned home.Because of this lack of therapeutic success, a new- pediatric-psychiatric team composed of the authorswasset up. Thepsychi-atric members of the team, who came from a background of familytherapy, set outtoinvestigatetheroleofthefamilyinthechild'sillness and, equally important, to explore the function of the child'sillness inthefamily.1 Thepediatricmembers of theteamset astheirtaskthestudyofthemediatingmechanismsbywhichemo-tional arousal could be translated into diabetic acidosis. In the end,thesetwoareasofinvestigationmerged, whenit wasshownthatthe emotional arousalof the child anditsmetabolic consequencesarebest documentedwithinthefamilycontext.The Metabolic StudiesForachild withdiabetestogointoacidosis, theremustbeapre-ceding rise inthe concentration of freefattyacids (FFA)foundinthe blood. These acids are the substrates or ttbuilding blocks"from which the liver produces the excessive amounts of ketone bod-iesthatgiverisetothediseaseofketoacidosis. Previousobserva-tions inthefieldof psychophysiologyhadshownthat free fattyacids can also serve asa marker for emotional arousa1.2In thedia-betic child there is thus a measure which at one and the same timereflectsemotionalarousalandsignalstheadvent ofthepsychoso-matic symptom. As researchers, we therefore began to set upexperimental situations in which changes in FFA were used to docu-ment the relationship betweenemotional arousal andpsychoso-matic crisis.At this time, thephysiological studies continuedtobeshapedbythelinearframework. We wantedtoassesstheroleofpsycho-logical stressinthecontrol ofthechild'sdiabetes. WeknewthatThe Psychosomatic Family / 27freefattyacidswerebothamarkerfor emotional arousal andametabolicintermediaryfor theproductionof excessive amountsof ketones, and that they could therefore be viewed as a key link inthe sequence throughwhichemotional arousal canbe mediatedintodiabeticacidosis. A seriesofinterviewstoexploreanddocu-ment this sequence was designed. The families of the childreninvolvedwereinformedas tothenatureandpurposeof thein-terviews and gave their informed consent for the children'sparticipation.Two interviews compared FFA levelsin thediabetic child underboth nonstressful and stressful conditions. The stressfulinterviewwas designedtoelicit thechild's anger but at thesametime toinhibit her repression of this emotion-a design based on theclassiclinear model of psychosomatic disease. Athirdinterviewtestedtheeffectsofabeta-adrenergicblockingagent ontheemo-tionalarousal asmeasured by ariseintheFFAsequence. Abeta-adrenergic blocking agent does not interfere with emotional arousalbut will ultimately block the release of free fatty acids. The resultsof theseexperiments wereimpressive. Emotional arousal inthestressful interview was accompanied by a dramatic rise in the con-centration of free fatty acids, which if sustained could have quicklyled to diabetic acidosisi11 the child. These metabolic consequenceswere, however, almost completelyabortedinthethirdinterviewwith the introduction of the blocking agent.This indication that the physiological consequences of emotionalarousal can be altered by the use of beta-adrenergic blocking agentsledtolong-termtherapeutictrialsofbeta-adrenergicblockadeinthe affectedchildren. Theearlyresults of this therapywere en-couraging. Longer experience, however, has indicated that the beta-adrenergicblockadeapproachisnot apanacea. A psychosomaticcrisisinchildren withdiabetescan breakthroughthebetablock-ade, just asinsulin'seffectiveness can beinhibited.:lTheseexperimentsrepresentedanattempt bothtoanalyzethemediatingpathways bywhichemotional arousal is convertedtodiabetic acidosis, and to gain more specific information abouttlstress," or exactlywhat it is that canproduce disease inthesechildren. The research was still constrained within the linear model,the family environment beingviewedas one of several noxiousfactorsimpinging upon the child. Then one of our patientscausedustore-evaluatethisthinking.28 / Psychosomatic FamiliesThe child inquestion hadaveraged one hospitalization everythree weeks for diabetic acidosis for a period of two years. Despiteweekly sessions with a psychiatrist, oriented around individualpersonality and coping issues, no change had been seen inthe pat-ternof heradmissions. Itwasthendecidedtotakethechild andher familyintofamilytherapy.We as family therapists tried an approach diametrically opposedtothetacktakenbythepsychiatrist whohadpreviouslytreatedthis child. Instead of assuming a supportive role to shield her fromstress, wedeliberately inducedfamilycrises. Thestrategy wasde-signed to actualize hidden conflicts in the session, to help thefamily deal with them, and to help the child engage in these conflictsas an autonomous individual.Thetherapysessions, oftenquitedramatic, wereaccompaniedby a change in the pattern of hospital admissions. The child, havingpreviouslybeenadmittedfor acidosis everythreetofour weeks,nowenteredthehospital inacidosis everyweek. Thefamilyses-sions were held on Tuesday afternoon; thechild wasregularlyad-mittedsometimebetween MondayeveningandTuesdayevening.Duringthesedifficult weeks, when both pediatricians andpsychia-trists wererespondingtoeachepisodeof acidosis at nomatterwhat timeit occurred, thepediatric-psychiatricteamwasforged.The psychiatrists felt free to continue this interventionist approachbecause ofthebackupsupportofthepediatrician, andthepedia-tricianwasreassuredbyseeingthepsychiatrists' commitment tothe patient during bedside family therapy sessions held in the mid-dleofthenight after theacuteacidosishadbeencorrectedwithintravenousfluidsandinsulin.Afterseveral months of familytherapy, major changes wereob-served in the family and in the child's role in her family. In particu-lar, the parents were able to initiate and negotiate conflicts withoutinvolving their daughter. Concomitant with these changes, the pat-ternofhospitalizationswasbroken.4Thiscasehasnowbeenfol-lowedupfornineyears. During that time, thechildhasnot oncebeen hospitalized forinexplicable ketoacidosis.As wereviewedtheresearchandtreatment results inthe dia-beticchildren, it becamemoreandmoreapparent that wewerewitnessingtwo sides of thesamecoin. Emotional arousal couldproduceelevationsofplasmafree-fatty-acidconcentrationwhich,in turn, couldleadto ketoacidosis. Inaddition, the more theseThe Psychosomatic Family / 29children were seen in therapy that involved and changed their fami-lies, the moreapparentitbecamethatarousal wasrelatedtothefamilyinspecific, testableways.Development of a Clinical ModelWhile working with diabetics, we began to study and treat childrenwith asthma whose clinical course was far moresevere than couldbe accounted for by the organic disease. At about the same time wealsobeganseeing casesof anorexia nervosa.Fromthebeginning,weconsideredthesethreegroupstorepre-sent different instances of psychosomatic illness. We distinguishedhowever, betweenttprimary" andttsecondary" psychosomaticdis-orders. In the primary disorders,aphysiologicaldysfunctionisal-ready present.These include metabolic disorderslike diabetes andallergic diathesis such as that found in asthma. The psychosomaticelement lies in the emotional exacerbation of the already availablesymptom. Thus, achild withdiabeteswhohasrecurrentboutsofketoacidosis triggeredbyemotional arollsal canbeconsideredattpsychosomatic diabetic." Likewise, a child with asthma whose re-current and severe attacks represent an exacerbation of the under-lyingdisorderinresponsetoemotional ratherthanphysiologicalstimuli can be termed a ttpsychosomatic asthmatic." In no way doesthisimplyapsychologicaletiology for theoriginal disease. Inthesecondary psychosomatic disorders, no such predisposing physicaldysfunctioncanbedemonstrated. Thepsychosomaticelement isapparent in the transformation of emotional conflicts into somaticsymptoms. Thesesymptomsmaycrystallizeintoasevereand'de-bilitatingillnesslikeanorexianervosa.Symptom choice may thus be differently determined in these twoinstances. We questionedwhether patients withprimaryor sec-ondary disorders might also differ in terms of their family dy-namicsandorganization. However, aswe workedintherapy withthe families of the children with these different psychosomatic pre-senting problems, we began to realize that certain transactional pat-terns seemed to be characteristic of all the families. The family of apsychosomatic diabetic functioned in significant ways very likethefamilyof ananorecticorapsychosomaticasthmatic. But thefunctioningof thesetipsychosomaticfamilies" differedmarkedlyfromthe functioning of the families of normal diabetics who came30/ Psychosomatic Familiesintotherapyfor other problems. Continuedimmersioninfamilytherapysessionspermittedustosharpentheseobservationsand,asourexperiencegrew, togeneralizefromfamilytofamily, untilwe finally evolved an exploratory model of the psychosomaticfamily.Four characteristics of overall family functioningemerged fromour observations. No one of these characteristics alone seemed suf-ficient tosparkandreinforcepsychosomaticsymptoms. But thecluster of transactional patternswasfelt tobecharacteristicofafamily process that encourages somatization. The four family char-acteristicsareenmeshment, overprotectiveness, rigidity, andlackofconflict resolution.Enmeshment refers to an extremeformof proximityand in-tensity in family interactions. It has implications at all levels: fam-ily, subsystem, andindividual. Inahighly enmeshed, overinvolvedfamily, changeswithinonefamilymemberor intherelationshipbetween two membersreverberate throughoutthesystem. Dialogsarerapidlydiffusedbytheentranceofother familymembers. Adyadicconflictmaysetoffachain of shiftingallianceswithinthewholefamilyasother membersget involved. Oronefamilymem-bermayrelaymessages fromanother toa third, blockingdirectcommunication.Subsystemboundaries inenmeshedfamilies are poorlydiffer-entiated, weak, andeasilycrossed. This situation results in theinadequate performance of subsystem functions. For instance, thespouse relationshipissubordinatedtocarrying outparentalfunc-tions. Or parental controlof childrenisineffective. Whenbounda-ries are crossed, children may act inappropriately parental towardparents or siblings. Or a child may join or be enlisted by one parentagainstthe other indecision making.On an individual level, interpersonal differentiation in an en-meshed systemis poor. Inall families, individual members areregulated by the familysystem. But in enmeshed familiesthe indi-vidual gets lost in the system. The boundaries that define individualautonomyaresoweakthat functioninginindividuallydifferenti-atedways is radicallyhandicapped. Excessive togetherness andsharing bring aboutalack of privacy. Family members intrude oneach others' thoughtsandfeelings. All theseproblemsofenmesh-ment arereflected inthe family members' poorly differentiatedperceptionsof each other and,usually, ofthemselves.The Psychosomatic Family / 31The overprotectiveness of the psychosomatic family shows in thehigh degree of concern of family members for each others' welfare.This concern is not limited to the identified patient or to the area ofillness. Nurturing andprotectiveresponsesareconstantlyelicitedandsupplied. Familymembersarehypersensitivetosignsofdis-tress, cueingtheapproachof dangerous levels oftensionorcon-flict. Insuchfamilies, theparents' overprotectivenessretards thechildren'sdevelopment of autonomy, competence, and interests oractivitiesoutsidethesafetyofthefamily.The children in turn, particularly the psychosomatically ill child,feel great responsibility for protecting the family. For the sickchild, theexperienceofbeingabletoprotect thefamilybyusingthe symptoms may be a major reinforcement forthe illness.Rigidfamilies areheavilycommittedtomaintainingthestatusquo. In periods when change and growth are necessary, they experi-encegreat difficulty. For example, whena childinaneffectivelyfunctioningfamilyreachesadolescence, hisfamilycanchangeitsrulesandtransactional patternsinwaysthat allowfor increasedage-appropriate autonomy while still preserving familycontinuity.But thefamilyof a psychosomatically ill child insists on retainingthe accustomed methods of interaction. Issues that threatenchange, suchas negotiations over individual autonomy, are notallowedtosurfacetothepoint wheretheycanbeexplored. Evenwhen coming into-therapy, these familiestypically representthem-selves as normal and untroubled, except for the one child's medicalproblem. Theydeny any need forchange in thefamily. Such fami-lies arehighlyvulnerabletoexternal events, suchas changes inoccupation orlossofkin. Almostany outsideeventmayoverloadtheir dysfunctional copingmechanisms, precipitatingillness.The rigidity and overprotectiveness of the psychosomatic familysystem, combined with the constant mutualimpingements charac-teristicof pathologicallyenmeshedtransactional patterns, makesuch families' thresholds forconflict verylow. Usually astrong re-ligiousorethicalcodeisusedasarationaleforavoidingconflict.As a result, problems areleft unresolved, tothreatenagainandagain, continually activating the system'savoidance circuits.Eachpsychosomaticfamily's idiosyncraticstructureandfunc-tioning dictate its ways of avoiding conflict. Often one spouse is anavoider. When the nonavoider brings up areas of difficulty, theavoider manages todetour confrontationthat wouldleadtothe32 / Psychosomatic Familiesacknowledgement of conflictand, perhaps, itsnegotiation. Oronespousesimplyleaves thehousewhentheothertries todiscuss aproblem.Many psychosomatic families deny the existence of any problemswhatsoever, seeII no need" ever to disagree, and are highly investedin consensus and harmony.Other psychosomatic familiesdisagreeopenly, butconstantinterruptionsandsubject changesobfuscateany conflictualissue before itisbroughttosalience. Familymem-bersquicklymobilizetomaintainamanageablethresholdofcon-flict. They achieve this control through position shifts or distractivemaneuversthat diffuseissues. Whether the .familieswithpsycho-somaticallyill childrenavoidor diffuse, aninabilitytoconfrontdifferencestothe extent of negotiatingresolutionischaracteristicof allsuch families. Normal familiesare abletodisagree.Thesearethefour general structural andfunctional character-istics that were identified as typical of families with psychosomaticchildren. However, whiletheyaredescriptiveofastress-inducingfamilycontext for a vulnerable child, the identificationof thesecharacteristicsalone wouldnothavemovedusfromalineartoasystemsexplanationfor theetiologyandmaintenanceofthepsy-chosomatic child's symptom. It was the observation of the circular-ity of feedback that necessitated the move to a neworder ofexplanation.Viewed from a transactional point of view, the patient's symptomacquired new significance as a regulator in the family system. Morespecifically, it became apparent thatthekey factorsupporting theparticular symptomwas thechild's involvement inparental con-flict. This factor,then, is the fifth characteristic of a psychosomaticfamily.Within the psychosomatic family context, the symptomatic childisinvolvedinparental conflict inparticular ways. Parentsunableto deal with each other directly unite in protective concern for theirsickchild, avoidingconflict byprotectivedetouring. Or amaritalconflict is transformed into a parental conflict over the patient andher management. In some families, the child is recruited into takingsidesbytheparents, orintrudesherselfas amediatororhelper.The effectiveness of the symptom bearer in regulating the internalstability of the family reinforces both the continuation of the symp-tom and the peculiar aspects of the family organization in which itemerged.In our therapeutic work with psychosomatic families, thereThe Psychosomatic Family / 33emergedcharacteristicpatterns of conflict-relatedbehavior thatinvolved the child. Families may move from one to another of thesepatternsovertime, butonetendstopredominate. Thethreecon-flict avoidance patterns of involvement that we identified weretriangulation, parent-child coalition, anddetouring.Inthe first twopatterns, triangulationandparent-childcoali-tions, thespousedyadisfranklysplitinopposition orinconflict,andthe child isopenly pressedtoally withone parent against theother. Intriangulation, the child is putinsuch aposition thatshecannotexpressherself without siding withone parentagainsttheother. Statements that impose a choice, suchas IIWouldn't yourather do it my way?" are used in the attempt to forcethe child totake sides. In a parent-child coalition, the child tendsto move intoa stablecoalitionwithoneparent against theother. The roleoftheexcludedparentvariesaccordingtothedegreethatheorshetries todisrupt the coalition.In the third type of pattern, detouring, the spouse dyad is ostensi-blyunited. Theparents submergetheir conflicts ina postureofprotecting orblamingtheirsickchild, whois definedastheonlyfamily problem. In some families, the parents require the childrentoreassurethemthat theyaregoodparents or to jointheminworryingabout thefamily. Theparentsoccasionallyvacillatebe-tween their concern forthesick child andtheir exasperationovertheburdensthat sheimposesbyII not tryingtohelpherself." Inmost cases, parental concerns absorb the couple, so that all signs ofmarital strife or even minor differences are suppressed or ignored.Thesethreepatternsofinvolvement arenot themselves familyclassifications. Theydescribe transactional sequences that occurinresponsetofamilyconflict. Suchsequences, whichoftenoccurineffectivelyfunctioning families, arewithin the wide range ofmethods that families use to cope with conflict. However, the fami-liesinthenormal rangecanshift toothermodesofconflict con-frontationandnegotiation. The familieswithapsychosomaticallyill child enact maladaptive sequences again and again. Because theyareusuallyoperatingunder conditionsofstressandtension, thechild is frequently involved in the role of conflict defuser.Verification of the ModelThedevelopment of theexploratorymodel inthecontext of thefamilytherapysessionswas exciting, andit helpedus greatlyin34/ Psychosomatic Familiesorganizingour thinking. But inorder totest thevalidityof thismodel, it wasnecessarytoconduct amoreformal study. Specialtechniques had to be developed to permit the collection of quantifi-able data in a behavioral domain comparable to a therapeuticinterview.In order to take a more rigorous look at the firstfourcharacter-isticshypothesizedasbeingtypicalof psychosomaticfamilies, wedeveloped a standardized interview that enabled us to analyze eachfamilyasit carried outaseriesof familytasks. Thisapproachre-quired usto operationalize our concepts by identifying specific be-havioral referents for themin each task. It also allowed us tocompare psychosomatic with nonpsychosomatic andnormalfami-lies, for whomtherapymaterial wouldhavebeenunavailableornoncomparable.The observations told us little about such factorsas intrapsychicdynamics, individualpsychopathology, orthe strengthsandweak-nesses of individual family members. These aspects of functioning,though real, could have been studied through other types of assess-ment, such as questionnaires, projective tests, and individual inter-views with each family member.However,those other tests wouldnot have enabled usto evaluate the familyrelationships, whichre-quiredirect observation of the family in action.Similarly, in order toexplore ourhypothesesabouttheinvolve-ment ofthechildinparental conflict, wedesignedafamilydiag-nosticinterview whichrecreatedaconflict situationinthefamilyandopenedtheensuingfamilytransactions toobservation. Thisbroadening of the observational field not only provided the neededdata but also fosteredthe emergence of new data and new aspectsof what wasbeingseen. We werealsoabletoassessphysiologicalindicatorsof emotional arousal directly, viaFFAmarkers, inthisexperimental family stress context.Altogether, forty-fivefamilieswereinvolvedintheresearch, allof whomwerestudiedpriortotherapy. Thethreepsychosomaticgroups whoparticipatedincludedelevenfamilies withanorecticchildren, nine' familieswithpsychosomaticdiabeticchildren, andten families with asthmatic children. There were two controlgroups: seven familieswith normal or nonpsychosomaticdiabeticchildren, and eight families with diabetics whose illness was undergoodmedical control but whohadbeenreferredfor behavioralproblems.The Psychosomatic Family / 35Inall thepsychosomaticcases, frequent andseveresymptomsthat could not be explained on any organic basis were present. Thediagnosisof psychosomatic wasalwaysmadebythepediatrician,who indicated that there were noorganic or physiologicalreasonsforthedifficulty of medicalmanagement.The two control groups of diabetic children were studied in ordertocompare themwith the psychosomatic children. The normaldiabetic children wereincluded becausetheyshared withthepsy-chosomatic patientsaserious chronic illness, withall that thisen-tails for thefamily. Thebehavioral diabeticchildrenprovidedauseful comparison, first because they were identified as psychiatricpatients,similar in thisrespecttoallthreepsychosomatic groups,andsecond because they werp, behavioraldeviants, unlikethepsy-chosomaticdiabeticsandasthmatics butsimilartotheanorecticsfromafunctional pointof view.The Family TaskThe family task administered in our study was an elaboration oftheWiltwyckFamilyTask, whichinvolvesengagingthefamilyinaseriesof interactive tasksthatthey administer andcarry out bythemselves.5Thistechniquehastheadvantageofenablingthere-searcher to study the family in a quasi-natural situation without theshapingofaninterviewer. Thequestionsarerecordedonatape,which the family members start and stop by themselves. They seatthemselvesastheywish. Theyanswerornot; theyunderstandoravoid. In short, they make it their own family task.Each family was asked in succession to make up a menu together,todiscuss a familyargument, todescribewhat pleasedanddis-pleased them about other family members, to make up stories aboutfamily pictures, and to put together a color formsdesign(for com-plete protocol, see Appendix A). Two siblings were requested to joinwiththe identifiedpatient andparents incarryingout this pro-cedureinordertoget amorecomprehensiveviewof thefamily.All of the transactions were videotaped and, subsequently, counted,rated, andscoredbyindependent raters.Amajor task for the experimenters was to operationalize the con-cepts of enmeshment, overprotectiveness, low tolerance for conflict,andrigidityso thatthey could be assessed in the family'stransac-tions around carrying out the task. Enmeshment, for example, was36 / Psychosomatic Familiesscoredat threelevels: family, subsystem, andindividual-interper-sonal. Information fromthe task items was utilized within each ofthese areas. The scores at the family level reflected the family func-tioning as a whole. To evaluate this area, the pattern of communica-tions was examined. The extent to which people acted as communi-cationgo-betweenswas measured, as was thedistributionof thespoken transactional sequences to, through, andaroundcertainfamilymembers. Shifting alliances, definedasarbitrary andalter-nating switches of support fromone member to another, wereratedasanindexofoverall familyenmeshment. All ofthesefac-torswereseenas indicators of theexcessiveinterdependenceoffamilymembers.Theassessment ofenmeshmentat thesubsystemlevel focusedon the clarity of boundaries between the parents and the children.First, the quantity, effectiveness, and unity of the parents' executivebehavior in controlling the family in the process of performing thetask were objectively rated and counted. Secondly, both cross-sub-systemalliances, suchasparentandchildversusparent, particu-larly in relation to executive activities, and the executive dominanceofoneparent as comparedtotheotherwereexamined, becausethese factors were considered to reflect the weakening of subsystemboundaries. Finally, individual-interpersonal differentiation was re-flectedin the degree to which individualized percepts andexpecta-tions of other familymembers emergedineachone's likes anddislikes, andintheextent towhichfamilymembers II read eachother'sminds"oransweredfor anotherperson.An overview, however, of thebehavioral definitions, quantita-tivedata, andanalysesisall that isneededhere; amoredetailedreport isgivenelsewhere.6Althoughthetrendsreportedherearedescriptiveandclinical intone, theyrepresent formal categorieswhose reliabilities andsignificance levels have beenestablished.The results are presented so asto contrast the anorectic group withthetwoother psychosomatic groups(asthmaticanddiabetics) ontheonehand, andwiththecontrol groups (behaviorals andnor-mals)onthe other.Normal familiesdiffered most fromthe othersontheindicesofenmeshment, being particularly strong on clearsubsystem bound-aries andhavingahigher degreeof interpersonal differentiation.While behavioral problem familiesshowed poor parental executivef11nctioningintermsofeffectiveness, theanorecticandotherpsy-The Psychosomatic Family / 37chosomatic familieswere most deficient in parent-child subsystemdifferentiation. A child, for example, would run the task or consultwithoneparent about what toadvisetheother parent. Inthesefamiliesthere was more imbalance withinthe parentalsubsystenl,sothat one parent woulddo most of the executive work, directingactivitiesandmanagingthefamily, whiletheother parent joinedthechildinrespondingtothismanagement. Ontheinterpersonallevel familymembers wereintrusiveandtendedtobeglobal inexpressingtheirperceptsof otherfamilymembers. Forexample,instead of saying what they liked or disliked about husband or son,motherswouldsay, III likeitwhenwe'reall happytogether,"orIII'm unhappy when the kids fight."On afamilylevel, all of thedysfunctionalfamilies, bothpsycho-somaticandbehavioral, showedaskew orunevendistributioninthespeakingpattern. But theanorecticandotherpsychosomaticfamilies were most likely to have members who acted as mediatinggo-betweens. For example, in one familyall of the membersspokeonlytothemother, whileshe, themost talkative, communicatedwithall ofthem. Inotherfamilies thememberspassedmessagesback and forththrough one another. Insum, whereassome of thebehavioral familieswereenmeshedaccordingtothecriteria, andsomeof thenormals showedoccasional enmeshedbehavior, theanorecticandpsychosomaticfamilies as agroupweremoreout-standing in this multifaceted dimension.Overprotectiveness wasassessedbehaviorally, both by countinginstancesof nurturant-protective or protectiveness-eliciting behav-ior, andbyanalyzingthecontent of thefamilyargument andofotheritemsfor protectivethemes. Thebehavioral measureswerethemoredefinitiveindistinguishingthenormal diabeticfamiliesfrom the anorectic and psychosomatic groups. For example, cryingbyaparent, child, orsiblingoccurredonlyinthepsychosomaticfamilies, asdid concern about hunger and physical comfort.The evaluation of conflict avoidance and diffusion was more com-plex, requiring considerationof the makingof simpledecisionsinadditiontothehandlingofargumentsandreal conflicts. Normalfamilies wereabletobothagreeanddisagreemore, just as theywereabletoconsidermorealternatives. Occasionallytheydeniedhaving any arguments or llfights," but they were able to state issuesclearlyandtoresolvetheminsomesatisfactoryway. Thebellav-ioral families tended to diffuse an unresolved conflict, but they were38 / Psychosomatic Familiesmore able to express conflict directly than the psychosomaticgroups. Some anorectic families agreed on everything instantly, de-nied orsuppressed any mentionof conflicts, ortookadvantageofthe anorectic child's noncompliance with the meal-planning task toskipthroughtheintervieworfocus onlyonher. Otheranorecticfamilies went onandonabout poorlydefinedarguments, whichthey then rejected as unsuitable forthe task. In this area, asin theassessment of protectiveness, the transactional behavior was morediscriminatingbetweenthegroupsthanwas thecontent oftheirtaskresponses.Thefinal characteristic,rigidity, wasthe most difficult todefinein terms of family task performance. We have begun to look at theextent towhichalliancepatterns, namelytheways inwhichthefamilymembersgroupthemselveswith regardtosuch mattersasmakingchoices andsupportingdecisions, areflexibleanddevelopinrelationtofunctional or objectivetasksandtopicsrather thanbeing fixed or bound regardless of the issue. For example, a motherin afunctionalfamily supported her daughter's foodsuggestion inmaking upamenu but united with herhusbandaroundsettingafamilyrule. In thedysfunctionalfamilies, itseemed thatalliancesusually endedup in fixed patterns. For example, a father whostartedout supportingsomeoneinthefamilyonanissuewouldalways shift, ending up in support of a particular daughter, regard-less ofwhatever positionsheembraced. However, further opera-tionalizing of this factor in family interaction is necessary.The Family Diagnostic InterviewWhilethefamilytaskprovidedtheopportunitytostudythefourstructural characteristicsofthefamilyfor a time-limitedperiod,it did not usually reveal the way in which the vulnerable child wasusedtodetourconflict. Thefamilywasincontrolofthesituationand could to a large extent avoid stress or conflict. The family diag-nosticinterviewwas thereforedesignedinorder toassess simul-taneously the child's involvement in parental conflict and the physi-ological effects of parental conflict on the child's disease.Theideaofthis interviewwas tobringabout conflict betweenthe parents, based on issues that were idiosyncratic to each family.A therapist would exacerbate the conflict beyond the family's usualthreshold of tolerance and then, when the conflict was at its height,The Psychosomatic Family / 39bring thechild intothesituation. The triadicinteraction could beevaluated forboth itspsychological content andthephysiologicalconsequences.The interview was also employed to verify a theory we had formu-lated during familysessions aboutthe development of apsychoso-matic crisis. We hypothesized that it consists of two phases, whichencompass bothpsychological andphysiological components. Inthetl turn on" phase, asituation produces emotional arousal in thechild, which in turn triggers physiological responses. At some laterpoint there is a time fortl turn off," with a return of the physiologi-cal responsestoward baseline levels.A psychosomatic crisiscouldtherefore be related tothe exaggerated nature of the physiologicalresponsesintheturn-onphase, or it could be duetodifficultiesinthe turn-off phase. The family diagnostic interview, by eliciting idio-syncratic family conflict and involving the child in parental conflict,enabled usto study the physiological responses of the child to heremotional arousal in both the turn-on and turn-off phases.Animportant feature oftheinterviewwas thecombinationofnaturalistic observation with the experimental manipulation offamilyvariables. Theidentifiedpatient was seenina significantnatural context: she was in atransactional situation with her par-ents, interacting around issues selected by her parents and particu-lar to that family. It waspossible not only to understandtheindi-vidual patient's experience and behavior better, but also to evaluateher parents' experience of her, as well as the ways in which the threefamily members regulated each other's behavior. Atthe same timethe experimental format permitted the manipulation of the idiosyn-craticfamilyvariables-suchas toincrease the intensityof theconflict by handicapping escape, by supporting one member againstanother, or by prolonging the duration of the conflict-even thoughthe familymembers evolvedits content bythemselves. Unfortu-nately the complexities of developing the experimental situation didnotpermittheinclusion ofsiblings, aswaspossibleinthefamilytask.The format of the familydiagnostic interview wasstandardizedtocomprisethreestages. Instageonetheparentswereseatedinaninterviewroom, withthechildinanobservationroombehinda one-way mirror. Heparin locks (intravenous blood sampling units)had earlier been inserted inthe armof each familymember, afterwhichthere had beenahalf-hour equilibrationperiod. Duringthe40 / Psychosomatic Familiesinterviewthearmattachedtotheunit was allowedtorest onatable behind ascreen. The lab personnel remained out of sight be-hindthis screen, wheretheycoulddrawbloodsamplesunobtru-sively. After the parents had been seated, the psychiatric inter-viewer told themto discussafamily problem, andthenleft.After half an hour the interviewer returned, for the start of stagetwo. Using the technique of supporting one spouse against theother, heattemptedtoexacerbate, or insomefamilies toelicit,family conflict around the issues that they had chosen. At the end ofanother half-hou