A 26-year old patient of mine, Andrea, came to see me for help with her
tendency to binge on food and then make herself vomit, almost every day.
She had tried conventional, insight-oriented psychotherapy and
antidepressant medications to no avail.
During my initial evaluation of her, she expressed a desire to lose
weight (she was moderately overweight) and to become more fit. In
particular, the flabbiness of her abdominal muscles troubled her, for
the summer was approaching and she hoped to look good in a bathing
suit. She had put off joining a health club for a couple of years, probably
from her characteristic laziness, she said.
I asked Andrea to agree to perform a particular task at home
whenever she binged. Performance of this task was likely, I said, to
resolve her binging, would not violate her moral principles, and would
be good for her. But I would not tell her what the task was until she
agreed, so as to establish her commitment to take action. After a
little hesitation, she agreed.
Any time she binged, I directed, on that night she was to set her
alarm for 3 AM, arise, and perform 30 minutes of abdominal
exercises–situps, crunches, planks, and the like.
When we met in three weeks, she reported that she had binged
only once during that time, performed the abdominal exercises as
instructed, and then seemed to lose her drive to binge. During the
next 8 weeks, with our agreement still in effect, she did not binge.
Moreover, she joined a health club and began working out on a
regular basis. Treatment ended with her awareness that she
possessed the ability to stop the binging if it ever recurred.
Andrea’s treatment exemplifies ordeal therapy, described in Jay
Haley’s book of that name. With this intervention, the therapist
links the future occurrence of symptoms or problematic behaviors
with another behavior that the patient is to deliberately perform.
The enactment, or threat of enactment, of this prescribed behavior,
changes the meaning of the problem to one that is incompatible
with a continuation of the problem. For example, the prospect of
the exercises changed the meaning of Andrea’s binging from an
undesirable but also gratifying symptom to something that was
both highly unpleasant and good for her.
We can more easily alter our behaviors when the meanings of
those behaviors change for us. Changing the meaning of patients’
problems, known as reframing, is a core concept in the practice of
the group of psychotherapies that we can label collectively the
strategic psychotherapies (a term popularized by Jay Haley). The
ability of effective reframing to change patients’ attitudes about
their problems brings to mind Alfred Adler’s witticism: “Therapy is
like spitting in someone’s soup. They can continue to eat it, but
they can’t enjoy it.”
As in Andrea’s case, strategic therapists do not attempt to
promote insight in their patients, as they believe it is a relatively
unimportant contributor to the solution of psychological
problems. Instead they attempt to change the patterns of
patient’s behaviors, often with directives, homework tasks, or
suggestions (sometimes hypnotic).
Others besides Jay Haley who have written about strategic
psychotherapeutic approaches include Milton H. Erickson
(Haley’s book, Uncommon Therapy, about Dr. Erickson’s work,
represents an outstanding introduction to this kind of therapy);
Gerald Weeks and Luciano L’Abate in their book, Paradoxical
Psychotherapy; Paul Watzlawick; Richard Fisch, John Weakland,
and Lynn Segal in their book, The Tactics of Change; and
I have used the therapeutic ordeal successfully, not only for
bulimia, but for other symptoms like panic attacks and
obsessive-compulsive behaviors. In general, well-chosen
strategic interventions like the therapeutic ordeal can work
with extraordinary rapidity.
There is one issue that deserves further comment here. That
is the belief that if you remove symptoms from a patient,
especially without benefit of insight, other symptoms are bound
to replace them. In my psychiatric residency, most of my
supervisors, almost all of whom were Freudian psychoanalysts,
believed this. However, this is not what happens in reality, at least
most of the time. Instead, we tend to see what we term a “ripple
effect,” in which the solution of one problem enhances patients’
self-esteem and confidence, and seems often to trigger further
beneficial changes in their lives.
In my next post, I will describe another powerful strategic
psychotherapeutic tactic, one which patients routinely consider
bizarre until they discover that it really works.