Prison of Food

Research and Treatment of Eating Disorders

Roberta Milanese, Giorgio Nardone, Tiziana Verbitz, Roberta Milanese, Giorgio Nardone, Tiziana Verbitz

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429917547
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This groundbreaking volume concentrates on solution-oriented treatment of some of the most difficult pathologies - anorexia, bulimia and vomiting (as a separate category introduced by Nardone et al). The logic and apparent simplicity of the way these complex conditions are treated is truly outstanding. As opposed to a long-drawn psychotherapy, Nardone and his colleagues offer a relatively short period of treatment, consisting of dialogue between the patient and the therapist, and sometimes the patient's family. The patient is also given some "homework" to do in-between the sessions. Rather than looking at the "why" of the situation, this approach looks at "how" the problem manifests itself and what can be done about it. The book starts by outlining the pathologies and the logic behind this type of brief therapy. It then moves on to examine particular case studies and the reader gets immersed in the fascinating dialogue between the therapist and the client.

Chapter One

From descriptive to operative diagnoses

Words ordered differently produce different meanings; and meanings ordered differently produce different effects.

Blaise Pascal, Pensées (1670)

The educated philistee assigns unconditional perfection and objective validity to a few principles and methods, so that, having found them, he can use them to judge any event, to approve or reject it.

Arthur Schopenhauer, The Art of Controversy and Other Posthumous Writings (1896)

Defining problems from an operative perspective

The first problem for clinical researchers is how to define the subject of their research. The configuration of the subject is a matter closely connected with a researcher’s theory of reference. Consciously or not, researchers filter the observed reality through their personal interpretive lens. Modern constructivist epistemology has emphasized the problem of the observer’s influence on the observed phenomena (Arcuri, 1994; Heisenberg, 1958; Rosenthal & Jacobson, 1968; von Foerster, 1987; Watzlawick, 1981), and pointed out how every action carried out in the search of knowledge places at the centre of its reflection not only the object under observation but also the subject who observes it.

Although this epistemological paradigm is now an important part of all scientific fields, including physics, most clinical psychologists and psychotherapists still believe that it is possible to obtain a pure objective description of studied phenomena. This is contrary to the constructivist point of view that there is no single reality, but many different realities that change according to one’s perspective. How and why we know establishes what we know (Salvini, 1988). Thus, we have different realities and different ways of conceptualizing problems for each different point of view. This is particularly evident in the study and solution of mental and behavioural problems, a complex field that is characterized by an increasing number of contrasting theories and corresponding therapeutic approaches.

This concept is best illustrated by metaphor (Nardone, 1998):

Once in Southern Italy, on a very hot day, a father and his little son started out on a journey with their donkey to visit some relatives in a distant town. At first, the father rode on the donkey while the son walked beside them. As they passed a group of people, the father heard them say: “See that cruel father! He rides the donkey and makes his little boy walk, on such a hot day!”. So the father dismounted and let his son ride the donkey. After a while, they passed another group of people. The father heard them say: “Look! On such a hot day, the old father has to walk while his young son rides comfortably on the donkey. What’s the world coming to?” When he heard that, the father decided that it would be best if they both rode the donkey. As they continued their journey, they passed another group of people. The father heard them say: “See, how cruel! Those two have no pity for that poor animal, which has to carry so much weight on such a hot day!”. So the father dismounted and made his son do the same. They continued their journey on foot. After a while, they passed another group of people and heard them say: “Look at those two fools, walking on such a hot day when they could be riding their donkey …” [Nardone, 1998, pp. 9–10]

Obviously, this story could go on for ever. It illustrates how there can be very different opinions and perceptions of the same reality and how people’s reactions change accordingly. It is interesting, for example, to observe how many different causal descriptions of food disorders there are based on scientists’ different perspectives.

Psychiatrists of the biological school believe that there must be a specific gene for each food disorder. Authors who subscribe to the theory of repressed memories believe that 90% of women who suffer from food disorders have undoubtedly suffered some sexual abuse in the past.¹ Psychologists who take a psychodynamic perspective believe with absolute certainty that food disorders are connected with a failure to overcome archaic complexes, particularly (since more women than men suffer from food disorders) the Electra complex. More up-to-date researchers, such as those who adopt the relational perspective, see mother–daughter dynamics or parental conflicts as playing an obvious role in the formation of food disorders. (Zerbe, 1993). In the past few years, a theory that classifies eating disorders with dependency disorders such as alcoholism and drug addiction has become increasingly popular, leading to the foundation of Overeaters Anonymous (OA) (Malenbaum, Herfog, Eisenthal, & Wyshak, 1988). Their basic assumption is that anorexia and bulimia cannot be cured, only managed through self-help groups.

However, apart from such parochial, self-validating, theoretical, and practical propositions, most researchers seem to agree that eating disorders are “a sort of functional adaptation to a reality that is perceived as unmanageable” (Bateson, Jackson, Haley, & Weakland, 1956; Costin, 1996).

The strategic–constructivist perspective (Maturana & Varela, 1980; Nardone, 1991; Von Foerster, 1973; von Glasersfeld, 1981, 1995; Stolzenberg, 1978; Varela, 1981; Watzlawick, 1977, 1981) does not rely on any theory about “human nature”, nor, consequently, on any definitions of “normality” or “pathology”, but considers human problems as a product of interactions between the subject and reality. It is a non-normative model that sees human problems as the result of a complex process of retroactions between the subject and reality, where a person’s efforts to change actually contribute to maintaining the problematic situation.

According to this viewpoint, a problem persists because of the solutions attempted² by the subjects and the persons around them in order to resolve the problem. When those attempts fail, they retroact upon the problem and complicate it (Nardone, 1994; Nardone & Watzlawick, 2000; Watzlawick, Weakland, & Fisch, 1974).

This leads to the formation of what we call a pathogenic “system of perceptions and reactions”,³ which expresses itself as an obstinate perseverance in using supposedly productive strategies that have worked for similar problems in the past, but that now, instead, make the problem reverberate (Nardone & Watzlawick, 1990) Indeed, the redundant repetition of failed attempts to solve the problem actually increases the problem instead of solving it, leading to the formation of an autopoietic cybernetic system of attempted solutions and persistence of the problem.⁴ This circular dynamic of interactions maintains the stability and equilibrium of the system despite the fact that it is dysfunctional for the subject.

The objective of strategic interventions, therefore, is to interrupt the vicious circle established between the attempted solutions and the modes of persistence of the problem. Using specific manoeuvres that have the power to subvert the pathogenic equilibrium of the system, such interventions aim to induce changes in the modalities by which these persons have constructed private, dysfunctional realities in the relational, cognitive, and emotional organization that underlies their disorder.

In order to solve a problem, we need to understand how the system of perception and reaction towards reality functions in the person’s here and now. In other words, we must try to understand how the problem functions, not why it exists. In that sense, we leave behind the search for knowledge based on why for a search of knowledge based on how—going from a search for the causes of a problem to a search for its modes of persistence. This allows the resolving process to evolve from slow, gradual solutions to rapid and effective interventions.

Applied research on this subject (Fiorenza & Nardone, 1995; Nardone, 1993, 1995a; Nardone & Watzlawick, 1990) has enabled us to detect a series of specific models of rigid interaction between the subject and reality. These models lead to the formation of specific typologies of psychological disorders that are maintained by reiterated dysfunctional attempts to solve the problem. Such attempts actually increase the problem that they are supposed to solve (Nardone & Watzlawick, 2000).

The evolved model of the strategic approach goes beyond the nosographic classifications of psychiatry and clinical psychology⁵ by adopting a model of categorization of problems in which the construct “perceptive–reactive” system replaces the traditional categories of mental pathology.⁶

This goes against the current tendencies of many therapists who, having initially rejected the usual nosographic classifications, now seem to want to resume their use. This is the case, for example, of Selvini Palazzoli, Cirillo, Selvini, & Sorrentino (1998), who divide anorexics into four typologies that correspond to four personality disorders listed in DSM-IV: dependent, borderline, obsessive-compulsive, and narcissistic. From our point of view, classification is just another attempt to force the facts to make them fit one’s theory of reference, because it turns out to lack any concrete value from the operative point of view.

In light of these theoretical–epistemological assumptions, it seems essential to make what we call an “operative” diagnosis (or “diagnosis–intervention”) when defining a problem, instead of a merely “descriptive” diagnosis. Descriptive perspectives such as that of the DSM and most diagnostic manuals, give a static concept of the problem, a kind of “photograph” that lists all the essential characteristics of a disorder. However, this classification gives no operative suggestions as to how the problem functions or how it can be solved.

By operative description, we mean a cybernetic–constructivist type of description of the modalities of persistence of the problem, i.e., the problem how feeds itself through a complex network of perceptive and reactive retroactions between the subject and his or her personal and interpersonal reality (Nardone & Watzlawick, 1990).

From an operative point of view, the models of persistence of a particular typology of problems are identified through applied, empirical–experimental research with the objective of preparing solutions that guarantee increasingly effective and efficient interventions.

According to this mode of research, which we call “research–intervention”, external observation does not allow us to understand how a problem functions; for that, it is necessary to try to change the way it functions. Indeed, observing how the system responds to the introduction of change is the only way to reveal its previous functioning. The basic premise of this mode of research is therefore “to know by changing”.

This methodology is perfectly in line with what Kurt Lewin defined as action-research in social psychology (Lewin, 1946), i.e., a research that studies the phenomenon in the field, empirically and experimentally, producing changes in events and observing the effects of those changes. Along the same lines, we also have modern cybernetic–constructivist epistemology, effectively expressed by von Foerster (1973) in his aesthetic imperative—”If you want to see, learn to act” and by von Glasersfeld (1981)—”Man can know only what he does”, and again, “Action constructs knowledge”.

On that basis, we maintain that it is possible to know a reality by intervening on it, because the only epistemological variable that we can control is our strategy, i.e., our “attempted solution” that, when it works, enables us to understand how the problem persisted and maintained itself. The logic of our research–intervention is therefore based on the construct “Knowing a problem through its solution” (Nardone, 1993), i.e., knowing a reality through the strategies that are capable of changing it.

If we transpose this construct into clinical research, it follows that a successful solution strategy, repeated on a large sample of subjects with the same type of disorder, enables us to reveal the model of functioning of the disorder.

The method of “knowing by changing” is analogous to a chess game in which each player discovers his adversary’s strategy by observing the moves made in response to his own. However, neither player will gain actual knowledge of the other’s strategy until the game is done or won, because only a successful strategy can reveal the adversary’s strategy. In later, similar games, the player will have available an already experimented successful strategy and be able to reach checkmate more easily and with fewer moves.

It is possible to operate in the same manner in the study of a psychological pathology: the therapeutic game opens with manoeuvres that, however minimal, are capable of introducing an initial retroactive effect. We then proceed step by step, adjusting the strategy on the basis of the patient’s responses while trying to lead him or her to change the perceptive, emotional, and behavioural modalities that are maintaining the presented disorder.

With all the necessary adjustments to the patient’s particular personal and contextual situation, the same strategy can be applied to pathologies that are isomorphic to the typology for which the strategy was constructed, thus increasing the efficiency and effectiveness of the therapeutic intervention. As a consequence, this intervention is not based solely on the therapist’s artistic creativity, but mostly on a strategy that has proved to be predictive as far as it effects are concerned.

This way of conducting the therapy as a systematic process of research also leads to a more advanced understanding of the modes of persistence of those specific disorders. This in turn leads to further improvements of solution strategies, in a sort of evolutionary spiral nourished by the interaction between empirical interventions and epistemological reflections, which leads to the construction of specific, innovative strategies (Nardone & Watzlawick, 2000).

In our study of the various forms of eating disorders, this methodology turned out to be an important instrument of knowledge from an operative point of view, as it had been in our previous study of phobic disorders. In fact, the data gathered during our research intervention not only enabled us to devise an effective psychotherapeutic model for the rapid solution of these problems, but also led us to produce an epistemological and operative model of their formation and persistence.

This methodology, whose primary aim was the devising of an effective and efficient clinical intervention, thu...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• ABOUT THE AUTHORS
• PREFACE
• CHAPTER ONE From descriptive to operative diagnoses
• CHAPTER TWO The construction of treatment protocols
• CHAPTER THREE Efficacy and effectiveness of the therapeutic model: results
• CHAPTER FOUR Anorexia: formation, persistence, change
• CHAPTER FIVE Bulimia: formation, persistence, change
• CHAPTER SIX Vomiting: formation, persistence, change
• Conclusions
• NOTES
• REFERENCES
• INDEX