Two of the most prominent pioneers in the family therapy of eating disorders have been Dr. Mara Selvini-Palazzoli from Milan, Italy, and Dr. Salvador Minuchin, originally from the Philadelphia Child Guidance Clinic. Although their techniques and language differ, they share certain goals in family treatment. One of these goals is to achieve more effective leadership by parents in the family system, with less involvement of the anorexic child in the running of the family.

Dr. Selvini-Palazzoli has speculated that there are hidden rules by which anorexic families operate. One such rule: “No family member has the right to assume leadership.” Shifting blame to another family member is a common practice in anorexic families, as is forming secret coalitions.

Dr. Selvini-Palazzoli also believes that the onset of symptoms occurs when the patient perceives that she no longer occupies a privileged position in the nuclear and extended family. For example, the patient sees it as a betrayal when her mother turns her affection toward a younger sibling and the father stands by, powerless to help. The patient then decides she needs to regain her lost status, and does so by adopting anorexic behavior, which forces the others to pay attention to her. The “perfect” child becomes a source of trouble when she realizes the power that her symptoms give her to control others.

In the past decade or so, Selvini-Palazzoli has shifted her approach to treatment from “paradox” to “prescription.” By paradox I mean a treatment strategy that appears – on the surface at least -to be headed in an opposite direction from the presumed goals of therapy. An example of a paradoxical strategy would be to praise the starving girl for her sacrifice and to warn her not to change too quickly, since doing so would upset the stability of her family. Although this technique sometimes shocked the family into making positive changes, Dr. Selvini-Palazzoli was troubled by some of the “side effects,” including among other things a high rate of relapse.

Her current strategy uses what she calls the prescription. Here’s how it works. In the first session, the entire nuclear family, plus some representative from the extended family -say an influential grandmother -is invited. Only the nuclear family (father, mother, siblings) is invited to the second session. For the third session, only the parents come in. This approach underscores the importance of the parents, first by removing the elder generation (the grandparents) and then the younger generation (the children).

During the third session, the parents are informed of a “secret plan” by the therapist: On prearranged evenings they will disappear from the home, leaving only a note that reads, “We shall not be in tonight.” (If there are younger children, the parents arrange for a baby-sitter and leave food in the refrigerator.) The parents are told not to reveal any details concerning their whereabouts or their activities to the rest of the family.

Dr. Selvini-Palazzoli reports that this “prescription” binds the parental couple more closely together and helps establish their role as family leaders. It also helps to draw the anorexic child closer to her siblings as they all struggle to cope with this bewildering turn of events in their family.

Comparing the styles of Dr. Selvini-Palazzoli and Salvador Minuchin is like comparing the musical Oklahoma! with the opera La Traviata. In Minuchin’s view, a person’s social context – including the family – lets her express some parts of her personality but suppresses others. Therapy restructures the context so that the more poorly developed part of the self can grow and emerge. For this reason Minuchin calls his approach “structural therapy.” Minuchin sees the sick child as the force that maintains the family balance; in his term, she is the homeostatic regulator – the emotional “thermostat” – of the family. Her job is to protect the family from change. The more successful she is, the more persistent her illness becomes.

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