Psychoeducation

The “Palazzoli” model is now well known to systemic therapists. However, in your book The Work of Mara Selvini Palazzoli (1), you give an account of the developments of this model up to its publication, in 1990. What changes would you include in your book after these almost seven years of work?

The form of our work has changed. Our old idea of the telephone contact with one member of the family, during which certain information was gathered, and the condition of beginning the sessions with the whole family carry risks of different kinds.

For example: if there are family secrets, the first session is going to be very confused; in cases where an individual therapy is under way, it is a problem; and if only one member of the family is interested in family therapy, the others will not know where they stand. We met many anorexic girls who said: “The first time, they took me somewhere and I didn’t know where I was going.”

The old method consisted of a telephone contact with the mother or the father, and very often the girl came here deceived. Currently, we are attempting a more collaborative kind of work.

Another change: in the preliminary sessions, we do work that we did not do before, work of psychological psychoeducation. It is a matter of explaining, in the case of anorexia for example, that we think there is a psychological language, so as to prepare the family for the work.

So there would be two phases: a phase of generic, psychological preparation, on collaboration within the family, in which we explain that this is a psychological problem, that it is necessary to reconstruct the history of the family and of the patient’s life in order to understand the reasons for the suffering, and so on.

After these preliminary meetings, which involve two or three sessions, once we have valued the participation of all the family members and gathered all the necessary information, we begin to enter into the relational hypotheses properly speaking, the emotionally most intense part.

Before, these preliminary sessions did not exist in the model and we started with the relational hypotheses; today we see the limits of that approach.

How do you define the subsystem for starting the preliminary sessions?

The definition of the subsystem follows a methodology. It is linked to the person who makes the first contact. It is that person who must come to the first session. The message would be, in the case where it is a father who calls, to convey to him how important it would be for the mother to take part and, only in the case of strong collaboration and motivation, for the children to attend. I prefer not to have a resistant patient at the first contact, even though, very often, one of the parents is not motivated. That is why we ask the father (in the example) to persuade the mother, and for both of them to be sure before including the children.

Then we will see the resistant patient. If the parents are convinced, it is much easier to talk with the identified patient. Especially in cases of psychosis or anorexia, where we very often meet very resistant patients.

Is it the parents who make the next call, after having convinced the patient?

There are very particular cases where we decide to conduct the consultation without the identified patient: if the patient is a severe paranoid or schizophrenic who refuses treatment, and at that moment it is impossible to involve him in the treatment. It is in any case important to work on why the patient became paranoid and psychotic. We have done it a few times.

In any event, the idea is to take into account how the contact was initiated, and by whom. If it is the patient who telephones, things are different. The patient’s availability is different. We would then discuss whether he wants to come with his parents or prefers to come alone first.

We are currently experimenting, for example in those cases where it is the patient who asks for treatment, with starting the therapy individually. After a certain number of individual sessions, we begin the family therapy with the individual therapist as supervisor of another therapist, who will be the family therapist. We have used this technique with fairly interesting successes.

For example, an anorexic young woman, fairly adult, who has a certain autonomy. She tells me she prefers to follow an individual treatment. But I am not certain she is ready for it, because in reality it is her parents who are forcing her to come. For me, it is a good idea to conduct an individual treatment with her, because she is twenty-seven, but I think it is important to integrate the individual work into the family work afterwards.

In any case, I plan to hold a preliminary session with her parents to gather information, but we have already agreed, she and her family alike, that in two or three months we will hold four or five sessions of family consultation.

It is something we have already done three or four times with success. After three or four months, the individual therapist knows the young woman well and is going to be a very particular supervisor of the family therapy.

Alliances and the therapeutic team

Wouldn’t there be a strong alliance between the individual therapist and the patient, even if the therapist is behind the mirror? Doesn’t that have an influence?

The family therapist is totally outside that alliance. It is going to be very powerful. I remember that in one case, during a family therapy session, many ideas that had been built with the patient individually were modified.

It is important that the family therapist does not let himself be influenced, within the family therapy, by the supervisor, because the aim of family therapy is to introduce a different point of view, one that can enrich the individual work.

In these cases of bulimia and anorexia, does the team work with a nutritionist?

No, we think it is contraindicated, because the problem of the therapy consists in convincing the family that the patient’s problem has to do with her life, with her personal growth, and not with an eating disorder. It is not advisable to talk about calories.

Matteo, don’t you have a clinical limit for this type of work? For example, a 20-year-old girl, amenorrheic, who weighs 40 kg and has an electrolyte imbalance, which implies a serious clinical risk… don’t you consult a physician?

Of course, if there is a disorder of that kind, it is important that there be follow-up by a physician; but if the therapy is going well, it is not necessary.

When the individual and family therapy does not succeed, physicians must be consulted. There is no really important problem of integration.

From my point of view, it is very different with a psychotic patient, where integration is much more important. With anorexic patients, I believe the psychological work is more important, from a clinical point of view, than the emphasis currently placed on the question of nutrition. The root is psychological, despite the number of dietitians, endocrinologists and so on who deal with anorexia.

In Italy, generally speaking, are there teams that always work with a nutritionist, and teams that start with sessions with a psychologist and, if necessary, consult a nutritionist, for example? Because in Argentina, the trend is to form multidisciplinary teams…

In some centers in Italy (especially hospitals), it is the physicians, and in particular the psychiatrists, who hold the leadership. So that psychological family treatment practically does not exist, or takes second place.

Here in Milan, in a clinic specializing in endocrinology, enormous numbers of anorexics are hospitalized and only medical work is done, which includes a psychiatrist on the margins of the treatment, prescribing antidepressants or neuroleptics; psychotherapy takes place outside the hospital. That is the hierarchy.

What do you think of the behavioral models, that is, those that propose rituals to the patient in relation to food?

I think the results are not good. The whole American experience of the seventies, the articles by H. Bruch proposing rewards for the anorexic if she gained weight, for me, it is madness! The results I see from a very behaviorist hospital are similar, and it seems to me that these methods run counter to the spirit of the therapy of anorexia. If the problem of anorexia is that of the terror of a position of passivity, of inferiority, all these hospital, medical interventions are very “passivizing.”

What is at stake is that the patient should be the protagonist of the risk… We have seen in the follow-ups that the results of our treatments are very good; there is an incredible difference from hospital treatments.

Gender and personality

How do you include the question of gender in your work?

In the book (2), we work on the relationship between the condition of being a woman and anorexia, in connection with the type of father in the family. The novelty we studied in the field of research on anorexia was to move from the idea that anorexics have a common personality type to the idea that there are very different personality types among anorexics and bulimics. We defined four distinct personality types. Anorexia and bulimia, in this perspective, are only symptoms; the underlying personality type may differ markedly from one patient to another. We also have a historical explanation: the anorexia of the past was a more restrictive anorexia, because it was associated with a dependent-obsessive-compulsive personality type.

In recent years, another type of anorexics has appeared, much more bulimic, associated with the borderline-narcissistic personality type. The personality type radically changes the problem of treatment: working with a narcissistic-type patient is not the same as working with a borderline-type patient.

You speak in terms of psychopathological concepts. Do they correspond to dynamic psychopathology?

Not particularly in the sense of descriptive nosology, but in the sense of personality theory. The ideas of developmental psychology, the ideas of Bowlby’s theory. This idea of defining a connection between a type of family and a type of personality seems interesting to us. Much more than the old connection between the type of family and the symptom, for example anorexia. That connection seems impossible to us, because within schizophrenia and anorexia there are totally different personality types. One cannot establish a type of family of the anorexic or a family of the schizophrenic. That was a historical failure, because it is a mistaken concept. The symptom is associated with the personality type and cannot be associated with the family type. A certain personality type, in a given family, is going to use different defenses against suffering.

Psychosis and the therapist’s place

In the field of psychosis, do you have new ideas?

In principle, no. We continue to work with family secrets, the misrecognition of reality; currently, in clinical terms, we work with the parents alone. We use a scheme similar to the one used with anorexics. The differences are technical details; for example, I have never held a session with an anorexic’s family without the patient in question, because it is always possible to involve the patient in the treatment, even a resistant one. With schizophrenic patients, we have had a lot of experience of working without the patient in the first part of the treatment.

We are preparing a book in collaboration with psychiatrists, people who work in a public service, to see how family therapy with psychotics is used in the public service as a complement to the ideas of psychiatry. It is interesting work, because the idea we are developing is that traditional systemic therapy was not really suited to the psychiatric context.

We are currently reflecting on how other models of family therapy may be better suited to psychiatric contexts. For example, a three-generational model, in which the concept of the parents’ suffering for their children is central, may be more useful in a psychiatric context than the classic systemic model of the child involved in the couple’s problem. The latter was a failure in the psychiatric context.

We think that the three-generational model, in this context, may be more successful, by linking the parents’ difficulties with their children to the difficulties they themselves experienced as children. From the point of view of the convening and the preliminary sessions, this model is less rigid. The setting also changes, for example in the number of sessions: the idea of brief therapy (five or six sessions) does not work in a psychiatric context.

A few years ago, when Cecchin came to Argentina, we discussed the therapist’s place, what he feels, what he thinks… What do you think about it today?

During the period of the “paradoxical phase,” the therapist was in a position of very strong implicit alliance with the patient and, from the emotional point of view, the experience was similar to the psychoanalytic experience, that is, one of a long evolution. There was a strong identification with the patient, despite a very provocative attitude. Then we moved on to the idea of neutrality, a very different idea from the previous one, which implied equidistance between the therapist and all the members of the family.

Currently, we think that pure neutrality was a very serious limitation of family therapy. We have now returned to the idea of a basic alliance of the therapist with the patient and with the weakest members of the family (who are often the women), in the project of building empathy with all the members of the family.

The starting point of this empathy is not born of neutrality, but of the protection of the weakest part of the family.

As for the therapist’s feelings, it is a technical question: that of their use in the session with the patients. We have worked on this in recent years, and I believe that the fact that the therapist feels good, bad or confused is a fundamental element of clinical work.

Currently, do you favor a particular type of intervention in therapy?

The idea is to conduct family sessions for four or five meetings, which allow us to establish a more precise therapeutic program for each family, without necessarily involving the whole of it but, perhaps, some of its parts. Thus, each program may be very different from the previous one; the idea is not to favor a specific intervention, but to take the cases one by one and build a specific strategy. There are seven or eight different strategies, which can range from individual therapy for the patient to a combination of individual therapy and therapy with the mother, or family therapy only.