This case illustrates a typical dysfunctional interaction between subsystems: individual, family, and school. As we shall see, the crucial therapeutic intervention was based on the therapist's successive operational choices.
A very worried father telephoned me to ask me if he could bring me his eight-year-old daughter, whom we shall call Lisa, because of her anorexia and rapid loss of weight. As always, I tried to elicit as much information as I could during the telephone call, such information, as we shall see, being indispensable for the formulation of hypotheses and hence of operative choices. It appeared that Lisa had lost a lot of weight the year before but had fully recovered in the summer holidays. However, soon after the beginning of the new school year (it was in November) she had had a relapse, this time very much more rapid and worrying. The whole thing, the father explained, seemed inexplicable because the girl went to a private school and had an excellent teacher who took a special interest in her. The family was made up of four members, including Lisa's sister, who was two years older. The father described her as an extremely bright and vivacious girl, quite unlike Lisa, who was said to be timid and an introvert. At the end of the telephone call I had to make the first decision: whether to see the entire family or just the parents. For two reasons, I decided to invite the parents alone.
My first reason was to make sure that Lisa would not be labeled as a patient. Had she come along to the interview, she would inevitably have been made to feel that "we are going there for your sake."
My second reason was to observe the parents' relationship and hence to deduce the relationship between them and their daughter. I had been struck by the news that Lisa's anorectic symptom had spontaneously disappeared during the last summer holidays. I postulated that although her anorectic behavior was rooted in several subsystems, it had been triggered off by the interaction between Lisa and her class at school (teacher and classmates). If possible, l would try to work with the parents without ever seeing the girl.
At my first meeting with Lisa's parents, I found myself face to face with a young couple who behaved in diametrically opposite ways. The father was a successful businessman, worldly, keen on social activities and on sports. The mother was a modest little woman of low social origins, devoted exclusively to her home and evidently accepting a complementary position vis-à-vis her husband. In the course of our discussion it became clear that the older daughter was considered a copy of her father, whereas Lisa, the younger, was considered a copy of her mother. For that reason, Lisa, unlike her sister, who went to a public school, had been sent from the first year of primary school (on her father's suggestion and with her mother's consent) to an expensive private school, both parents feeling that she had need of special help. However, enquiring into the details of Lisa's school life, I quickly deduced that she did not, in fact, benefit from her private education. The teacher, drawn into the family rules and probably beset with problems that had nothing to do with Lisa, had come to treat Lisa as a "poor little girl" in need of special care, thus isolating her from her classmates.
Periodically the teacher would summon the parents for a discussion, exaggerating her own dedication and the particular care needed to teach a girl who was so inhibited and perhaps a little retarded as well.
At the end of our first meeting, I felt clearly that I was being presented with a combination of three dysfunctions: that of the family, that of the interaction between the family and the school, and that of the class in which Lisa had been enrolled. In the family, the very interaction of the couple reflected the existence and consolidation of a myth, already extended to the second generation: in that myth there was a clear distinction between the strong and the weak, between the bright and the dull, and between protectors and protégés.
In the interaction with the school, the myth and rules of the family system were taken over whole, as unfortunately happens so often. (In Lisa's case, there was also a special. reinforcement: a good girl needing help is a godsend to any expensive private school.) However it was the third dysfunction, that of the subsystem of Lisa's class at school, which struck me as the trigger of Lisa's symptom. Here she experienced the intolerable climax of the whole chain of dysfunctions: the schoolmistress, turning her into a "case," had isolated her and had deprived her of the support and sympathy of her classmates.
Once I had framed this hypothesis I had to pick the best type of intervention. On which of the subsystems would it be best to act? On the married couple? On the school? On the teacher? Lisa's situation was desperate.
I rejected the idea of intervening with the married couple. The mutual relationship, inasmuch as it was sharply complementary, appeared to me functional enough for the needs of the two partners. Their myth of the strong and the weak did not seem to be downright pathogenic. I accordingly thought it best to explode the myth as it had been extended to the other subsystems. I did, however, reject the idea of intervening with the staff of the private school: there was a risk of becoming bogged down in sterile diatribes and making a bad situation even worse. I preferred to profit from the parents' anxiety, from their concern about Lisa, and to convince them that it was best to transfer the girl immediately to a public school. I carefully avoided voicing the least critical remarks about the parents, which is always counterproductive. I praised the father for his parental concern for Lisa and ... reserved my critical comments for an outsider! The teacher, in her zeal to help Lisa, had adopted false methods, creating an irreparable situation to which Lisa's relapse bore witness. There was no alternative; Lisa would have to be transferred to a public school immediately, regardless of her scholastic shortcomings. To Lisa, the parents had merely to say that they had decided to change school because they had realized that the situation had become impossible. The parents agreed. On the further pretext of economic difficulties, Lisa was transferred to a public school. I advised the parents not to tell the new teacher anything about what had gone before. Within two months of her transfer to the new school, Lisa had not only put on quite a lot of weight, but she was a contented girl and was counted among the best in her class.
During my fourth and last meeting with the parents, I noticed that the mother had changed. She now intervened spontaneously in the transactions and seemed more content and more self-assured. All this confirmed the systemic principle: every part of a system is related to all the other parts, and any change in one part causes a change in all the other parts and in the entire system. Lisa's escape from the range of the weak and the protégés had destroyed the myth and rules of the family, no longer divided into two subgroups, and hence had also altered the relationship between the parents, not merely by increasing their insight but also on the level of concrete experience.