Good-Bye Paradox, Hello Invariant Prescription


Good-Bye Paradox, Hello Invariant Prescription

Palazzoli and the Family Game

By Rich Simon

September/October 1987


Parents mildly chagrined at their rebellious teenagers, couples vaguely aware of something missing in their marriage, families who think it would be a nice idea to learn how to communicate better—steer clear. Milan's Nuovo Centre per lo Studio della Famiglia is not for you. This is not a center for your run-of-the-mill family problems; it's for the cases most therapists would consider impossible, like the "Santinis."

It's hard to imagine that Mr. and Mrs. Santini, both sourly avoiding each other's gaze right now, ever cared very much for each other. Nevertheless, they have stayed married for over 30 years, even though most of the time they live in separate residences. Of their five children, two are former heroin addicts and a third, 19-year-old Rudolpho, has had auditory hallucinations for the past year and insists his older sister speaks to him through the TV set. In their first session 60-year-old Mr. Santini accused 20-year-old Paolo, a handsome university student, of sleeping with the family maid. It was soon revealed, however, that it was actually Mr. Santini who was sleeping with her. Mrs. Santini is now threatening to get a divorce. After the second session, Paolo called the Center to report that his brother Rudolpho had propositioned him and told him, "I want to have your baby."

It is now the middle of the third session and the family's therapist, Mara Selvini Palazzoli, a small woman with an enormous, electric smile, is discussing the metaphorical significance of the presents that Rudolpho, the identified patient, gave his parents last Christmas—a big ornamental heart for his mother and a tiny walrus contained in a huge gift box for his father. "To mother, Rudolpho gave a heart, as if he was telling her, 'You have no heart; I will give you one,'" says Palazzoli with great gusto in her sonorous, dramatic voice. "To father, he gave a very, very small animal to make fun of him. He has treated him as a castrati, an impotent old man, as if he were saying 'Poppa, you are not giving me a very potent image of you.'"

So far, Palazzoli has kept up an almost constant barrage of what she calls "terrible questions," her method for quickly penetrating to the family's emotional core. She has asked Mrs. Santini why her husband cheated on her in her own home, inquired of Paolo whether he thinks Rudolpho's homosexual proposition was a message to his mother or to his father, and requested Rudolpho's help in understanding why his father sleeps with maids.

Meanwhile, the Santinis sit, almost motionless, as if mesmerized. Despite Palazzoli's provocative questioning, they appear fascinated by what is going on, as fascinated with Palazzoli as she is with them. Whatever terrible things she may be asking, her rapt attention, her expansive gestures, and that blazing smile keep saying to the family, "However uncomfortable this may make you, you can trust me. Nothing you can say will throw me off." But there's more than that—a kind of delight she takes in the whole process. It's as if she has never talked with a family as interesting as this one, never explored family relationships quite this baroque and intriguing.

Readers who associate Palazzoli with Paradox and Counterparadox, the celebrated book she co-wrote with Luigi Boscolo, Gianfranco Cecchin, and Giuliana Prata, may, at this point, be wondering what she is up to. That book proposed that client families enter treatment with both a request and a warning, a double-level, paradoxical message that goes something like, "Please change us/Don't you dare change us!" To deal with help-seekers who resist help, Palazzoli and her colleagues argued, therapists must be change agents who argue against change. At the heart of their paradoxical approach was an unswerving commitment to clinical neutrality and "positive connotation," a way of explain ing to the family how even the most troublesome symptom was ultimately in the service of family harmony.

But whatever happened to positive connotation and neutrality? And when is she going to advise the Santinis against change? Well, the fact of the matter is that Palazzoli's ideas about treatment have changed dramatically since the days of Paradox and Counterparadox. Right now with the Santinis, she's confronting what she calls the "dirty games," the maneuvers family members use to hide their coalitions and strategies for con trolling each other. It is Palazzoli's contro versial contention that schizophrenia always begins as a child's attempt to take sides in the stalemated relationship between his parents. And, what is even more controversial, she believes that she has developed an "invariant prescription" that can shake up the whole family game and, in the process, cure schizophrenia But first that game must be very clearly understood and that's what she's trying to do with the Santinis.

Uncovering the Dirty Game

By the late afternoon, the 70-year-old Palazzoli has spent nearly three hours interviewing the Santinis, including two lengthy consultations with two members of her current team, Stefano Cirillo and Anna Maria Sorrentino. The team thinks that the pieces of the family puzzle are finally falling into place. The session is moving towards its climax.

Turning to Rudolpho, Palazzoli asks, "If your mother wants to divorce, with whom do you want to live?"

"With Momma," replies Rudolpho, who has stayed at his mother's home since he first began showing psychotic symptoms. It is the first time that his mother, who early in their marriage left the job of child-rearing to her husband, has cared for her child.

"Why did you have to go mad to be with your Momma? Couldn't you do the same as a sane person? Wouldn't she have been moved by you if you had not gone mad?" asks Palazzoli.

"No," replies Rudolpho.

Turning to Mr. Santini, with a quizzical look, Palazzoli asks, "Can it be, sir, that by going to bed with the maid, you have put your son on the side of his mother?"

Behind the mirror Cirillo and Sorrentino are suddenly on their feet. They're afraid that the session has taken a wrong turn. "No, no. He's not siding with the mother," says Cirillo. "Mara's missing the point." He leaves to knock on the door of the treatment room summoning Palazzoli to come out. Excitedly he tells her what he has seen.

"Rudolpho wants to stay with the mother to subdue her, to go on with the game!" he says.

Palazzoli, who has been sitting with arms folded, looking up at Cirillo like an attentive school child, is now beaming. "That's wonderful!" she announces, arms skyward in a gesture of rejoicing. "Thank you so much." Turning to a visitor she says, "Now I can say good-bye to Rudolpho because we understand. According to our model, Rudolpho considers his father the loser. He wants to stay with his mother to kiss her, to be tender with her, to show his father that he, Rudolpho, is a true man, a big walrus. When you understand, everything is clear. But, to understand without the team is quite impossible."

Returning to the session, Palazzoli lays out the team's conclusions with great verve. There is nothing paradoxical about her goal of kicking Rudolpho out of his parent's relationship. "Rudolpho wants to grab from his mother the tenderness that his father, a perfect idiot, couldn't obtain. [Turning to Mrs. Santini] If you divorce, Madam, Rudolpho will have you there for 30 years, caressing him endlessly. [Turning to Mr. Santini] And while you lost the game, Mr. Santini, Rudolpho has won it already. He has got his mother, but the price paid is very high: he has to be psychotic. [Turning to Rudolpho] Now you, Rudolpho, are saying 'Good-bye Father, now I must go to live with my divorced mother, to get all the caresses that you, a sane person, were not able to get from her.' But it is a completely stupid project. [Turning again to Mrs. Santini] If you divorce, Madam, you will end up living with someone who will get you to submit. Rudolpho will push you around for years."

She then tells the parents that she wishes to see only the two of them next time and once again warns Mrs. Santini, "Don't forget about Rudolpho's project: to get you on your knees. To transform you into the warmest momma, he needs to act crazy. It's a Pyrrhic victory. For now this is it. Good-bye."

The Invariant Prescription

The Santini family has now completed the first phase of a treatment that Palazzoli has used with over a hundred families in the past seven years. What lies ahead is the invariant prescription, a fixed sequence of unusual directives that Palazzoli uses with all the families of schizophrenics and anorectics she treats in her research project. Among other things, the invariant prescription requires parents to disappear without forewarning or contact with their children or anybody else in the extended family. Beginning with a few hours, these mysterious outings can extend to whole weekends away. In one case, Palazzoli and her team had the parents disappear for an entire summer. It's a method that family therapist Lynn Hoffman, one of the foremost explicators of Palazzoli's work, has said, "cuts into every family triangle as far as the eye can see."

Palazzoli has reported that extraordinary family transformations take place when clients faithfully follow the entire series of prescriptions. Using this procedure she claims to have consistently brought about the "complete cure" of schizophrenia and anorexia. Much of her time these days is spent collecting data at her center to support her claim.

Just how to use the invariant prescription remains obscure. So far only a handful of therapists have traveled to Milan to observe Palazzoli and her team practice their new therapy. Never interested in training, Palazzoli is unconcerned with preparing clinicians to use her new approach. What is known about the invariant prescription has been pieced together from Palazzoli's rare public presentations over the past several years. Nevertheless, her latest work has already generated considerable discussion and criticism, much of it in reaction to an address Palazzoli gave at the 1985 meeting of the American Association for Marriage and Family Therapy.

At AAMFT, Palazzoli described the results of 19 cases in which she used the invariant prescription. In the ten cases in which families accepted and diligently followed the prescription, there was a complete alleviation of symptoms in the schizophrenic and anorectic identified patients. Concluded Palazzoli, "the therapeutic power of the invariable prescription, when obeyed, had now been confirmed beyond all doubt."

She also elaborated on her team's concept of the dirty game—"A game was dirty, in our opinion, when the actors resorted to foul means such as: subtle cunning, brazen lies, relentless revenge, treachery, manipulations, seductions, ambiguous promises, and ambiguous betrayals . . . Our hypothesis was that the psychotic behavior of the identified patient was directly linked to a dirty game. We were repeatedly able to confirm this hypothesis."

Some in the audience were appalled by Palazzoli's emphasis on dirty games, seeing it as a disrespectful and potentially destructive perspective to take on families. "The whole idea of 'dirty games' is based on a very negative idea about people's motivation," said one attendee. "It carries an enormous connotation of blame and disapproval. I just don't think it's useful for therapists to adopt an I'm-going-to-get-you view of human beings."

Others greeted Palazzoli's reports of dramatic results with skepticism and charged that she was making exaggerated and unsupported claims for her work In a pointed rejoinder to the publication of Palazzoli's address, schizophrenia researcher Carol Anderson (1986) wrote:

What... is the impact of claims, such as those made [in Palazzoli's address], of astounding results with a new method when the evidence for such claims is not apparent from the work reported? Unsubstantiated claims could be a major disservice to clinicians and families, who may experience their therapy as a personal failure when they cannot achieve these same results. Might this not cause, rather than alleviate, problems, by raising unrealistic hopes and expectations?

Said another prominent family therapist, "I was totally outraged by her claims. She never even said what her criteria for suc cess were. The idea that there is this magi cal cure for problems as difficult to treat as schizophrenia and anorexia is ridicu lous. It flies in the face of everything we know about human behavior."

Palazzoli, however, has long been more than willing to fly in the face of conven tional assumptions about behavior. Throughout her career as a therapist and researcher, a restless search for fresh challenges has alternated with total dedi cation to the projects that have seized her imagination. She has repeatedly reinvented herself and shifted her perspective to embrace a whole new range of ideas. Palazzoli has been psychotherapy's most operatic researcher, someone whose influence has been felt, not in the data she has furnished, but in her distinctive tales of therapeutic "miracles," "disasters," and "shocking discoveries."

Discovering Anorexia

After World War II, Italian physicians encountered a kind of patient many had never seen before. Parents started bringing in emaciated teenage daughters who refused to eat. The conventional medical opinion of the time maintained that these young women were suffering from Simon's disease, a disorder of the pituitary gland that affected appetite. Palazzoli, who was then a young physician specializing in internal medicine at the University Clinic in Milan, became fascinated with these young patients. If they were suffering from a purely endocrinological problem, why had so few cases of this malady been reported during the war years? Moreover, why did so many of these young girls go to great lengths to fool their parents into thinking that they were eating? And if these girls had a psychological reason for starving themselves, what could it possibly be. "During the war there was no food. Once the shops began to be filled with food again, there was an invasion of anorectic patients into the clinics," recalls Palazzoli. "Today we can see clearly that if there is no food, there is no way to use food to make a move in the family game. But then it was a great mystery." Palazzoli became so taken with this mystery that she decided to switch careers and become a psychiatrist. Over the next 17 years she emerged as one of Italy's most prominent psychoanalysts and the author of a book and many articles about anorexia nervosa.

In the early 1960s, however, Palazzoli became increasingly disenchanted with psychoanalysis. "I needed hundreds and hundreds of sessions to have some effect on my anorectic patients," says Palazzoli. "I decided psychoanalysis was not an adequate treatment for this illness." In 1967, searching around for another approach, she came to the United States and became interested in family therapy. Back in Italy she formed a group of psychiatrists to develop a new treatment approach. Says Palazzoli, "I was very arrogant. I did not want to invite family therapists from the United States to train us. I wanted to invent something different." Smiling broadly, she proclaims, "I wanted to be original."

For several years the group floundered, unable to fit together their psychoanalytic orientation and the new family therapy ideas. "We treated families with interpretation, showing them what was going on in the session," says Palazzoli. "We had very disappointing results." In 1971 the group split, with Palazzoli and three young psychiatrists, Luigi Boscolo, Gianfranco Cecchin, and Giuliana Prata staying together. They resolved to discard their psychoanalytic mind-set and develop a therapy founded on systems theory. To avoid being sucked back into conventional psychiatric thinking, they cut themselves off from the professional community and created a kind of intellectual island.

"We laughed a lot and enjoyed each other's company very much, but in a way we were like monks," recalls Cecchin. "We were afraid to be contaminated by non-systemic ideas. The Pragmatics of Human Communication was like our sacred text." The team would meet two days a week to see families together, two members of the team serving as co-therapists with the family while two watched behind a one-way mirror.

As first among equals, Palazzoli provided the team with clinical leadership. Dealing with the most difficult families, using a method that called for long intervals between sessions and uncompromising neutrality, Palazzoli remained faithful to her clinical theory no matter what the crisis. Once a panicked wife called to request an emergency session, saying that her exhibitionist husband was threatening to cut off his penis. "Do not accept any alliances," Palazzoli told the team member who took the call. "Tell her, "This is a surgical problem not a psychological one.' Let her know that we realize that she and her husband will suffer very much before their next session."

The team developed an approach that sought to shift the family system without either overtly challenging it or blindly succumbing to it. Each session had an elaborate structure including preliminary hypothesizing, repeated team consultations, and a questioning process that continuously tested the team's hypotheses. Sessions climaxed with a closing prescription in which the entire system of interactions around the presenting symptom was positively connoted and the family was typically advised against change. Without being told so, the family was left to ponder the cost of continuing on its present course.

Frequently these closing prescriptions sounded a bit bizarre, as bizarre as the family game they were designed to disrupt. Once, nearing the end of therapy with a family in which the eight-year-old named Claudio had been diagnosed as autistic, the team decided the parents were trying to lure them into extending treatment even though the boy was doing well. The team saw the parents as seeking to evade responsibility for their children and Palazzoli addressed the following prescription to eight-year-old Claudio and his mischievous five-year-old sister Detta:

"There is a city, a large city in England that's called London, where there are a lot of theaters .. . There is one theater where for the past 22 years the actors always act in the same play. They know it all by heart, and they play their parts every day, year after year, and they can never change it! The same thing has happened to your mother and father. Ever since they got married, they have been playing the same part. We heard it here today. Daddy played the part of the good and the healthy one, and Mommy played the part of the bad and crazy one. [At this, the father tried to laugh, and the mother remained with her head bowed.] We doctors have tried in every way possible to help them play different parts, where the father isn't always good and healthy and the mother bad and crazy, but we haven't been able to, not at all. So we have to give up, but we are putting all our hopes in you. We have seen how much you have changed, and because of that, we hope you can do something. Who knows, that in time, you won't get some idea of how to help your parents change their parts, since we haven't been able to do anything. We are going to give you a lot of time. We will meet here in a year— to be exact, next year on July 7.

Detta (immediately): But next year I have to go to school!

Claudio (chanting): School days, school days, no more baby games now.

Palazzoli: Surely, and you will have a lot to do, and you will learn a lot in school. Let's hope you get some ideas as to how you can help your parents change their parts, since we have not been able to. (Selvini-Palazzoli, et al., 1978)

Following the session, the team analyzed the impact of the prescription in this way:

The therapists had abdicated the parental role conferred upon them by the couple, declaring themselves incapable of responding to their expectations, metacommunicating upon the conflictuality of these expectations, and leaving the field. In such a way, they declared this task requested of them impossible to fulfill. At the same time, they asked the children to accomplish this impossible task in their place. Such a prescription is doubly paradoxical. The therapists not only were prescribing something which had been proven impossible for them to fulfill, but were prescribing something which the children had always tried hard to do. The children had reacted to this explicit prescrip tion by refusing the task, and leaving the field ("I have to go to school!") The parents were struck by this turning of the tables. They were the only parents left in sight, there were no other parents than themselves. (Selvini-Palazzoli, et al., 1978)

The team began to see dramatic shifts in families. "In a few sessions using the so-called paradoxical prescription, some of our most difficult patients gave up their symptoms and their families began to change," recalls Palazzoli. "For me, that was very important because as a psychoanalyst I never had such astonishing success.

The Word Spreads

Word of what the Milan team was up to spread slowly. One of the first American family therapists to become interested in the Milan team's work was Peggy Papp, today one of family therapy's leading trainers. In 1974 she managed to get a hold of a manuscript of Self-Starvation, a book written by Palazzoli but not yet published in the United States. It described, in part, Palazzoli's break with the analytic method and her team's use of rituals and paradoxical prescriptions in the treatment of anorectics and their families.

"I was taken with their ideas about paradox," recalls Papp. "They had gone beyond reverse psychology and just instructing oppositional people complaining of imaginary headaches to go home and start having headaches. They weren't just prescribing the symptom, but the family's whole reaction to the symptom as well."

That summer Papp arranged to visit Palazzoli and her team in Milan. "I was astounded by their discipline," recalls Papp. "They would meet for an hour before each and every session. Mara would read the minutes from the previous sessions and then the four of them would discuss the case with tremendous enthusiasm. They'd have lengthy conversations during the session and then meet afterwards to analyze what had gone on. It made every therapy session I had seen before seem haphazard and shoddy."

While the teams' methods had developed out of long deliberations about Batesonian epistemology, cybernetic loops and the pitfalls of Newtonian thinking, what impressed Papp watching them work was their flair for the dramatic. Says Papp, "They turned everything into a theatrical presentation.

With all their detailed questioning, they managed to take the hidden subjective life of the family and turn it into a heightened performance. Eventually each family's situation would take on the dimensions of a great opera"

After a week in Milan observing the team craft its unusual prescriptions, Papp returned to the Ackerman Institute both eager to try out new ideas and terrified at adopting the disengaged, neutral Milan stance. "My heart was in my mouth for the first few sessions," she remembers. "I was saying things to families that seemed absurd, crazy. I was deliberately exaggerating one part of the truth and it was a struggle to maintain my perspective." The results, however, were exhilarating. Papp grew almost giddy with the effects of her new tool. "Instead of trying too hard to persuade people to change, I was sitting back, throwing out messages, and watching families react in remarkable ways," recalls Papp. "I soon realized, of course, that paradoxical interventions don't always work. I later modified much that I learned from the team and put it in my own framework. But I discovered something very important about bypassing what I normally considered resistance. In some way, I was leaving the decision to change up to the family. I thought to myself, 'Oh, what a relief to have such a tool.'"

As the Milan approach became known around the world, many therapists were to have experiences that paralleled Papp's. An important impetus to the team's reputation came in 1977, a year before the publication of an English translation of Paradox and Counterparadox, at a special by-invitation-only conference sponsored by the Ackerman Institute. The Milan Team arrived a week early and taped a number of consultations with the most difficult cases the Ackerman staff could come up with. "Seeing the team work together was electrifying. They absolutely turned my mind around," recalls Lynn Hoffman. "Their method provided a way of exploring the underlying logic of the problem within the family."

Even those suspicious of yet another approach that claimed clinical miracles came away impressed. Recalls Betty Carter, director of the Family Institute of Westchester, "I can only describe myself as sitting there in a state of total skepticism, tapping my foot, with eyebrows raised, thinking, 'Okay, show me, Buster .. . show me your miracle cures.' I looked at their tapes through my theoretical orientation and I found all kinds of things wrong with them. I felt very critical. But then there was this little thing that told me something important had happened in the families ... I tried like hell to dismiss it because it was foreign to my orientation, but I couldn't." 

As the Milan team's popularity and influence grew, their critics raised questions about some of the tenets of their approach. "I think the Milan approach is based on an utter distrust of people," says Frank Pittman, long-time observer of the family therapy scene. "It's an approach that assumes people are more interested in defeating the therapist than changing. That's just fallacious. I don't think I'm that much less obnoxious than other therapists, but when I tell people what to do, they usually do it. And when the)' don't, it's because I've messed up the relationships so badly that they prefer to do the opposite of what I say."

"In 1979 I went over and spent a week watching the team work together," says Jay Haley, known for his strategic approach to therapy. "I thought they were doing very skillful interviews, but typically they did the same intervention at the end of the session—which was to tell the family to stay the same. It seemed to me they were still thinking like psychoanalysts, trying to stay neutral and relying on the same method in every case rather than taking a strategic approach and changing what they do with each case. I think 80 percent of their popularity came from their model of working together as a team. Most therapists starting out with families don't know what they're doing and like to have company. That way they don't have to take individual responsibility, which is a relief to a lot of therapists."

Perhaps the most telling critiques of the Milan approach had less to do with the original team's work than with the uses it was being put to. In their interest in the technical side of the approach, many therapists ignored the enormous effort the team put into understanding what made a family tick They failed to realize that much of the credibility of the paradoxical prescription with clients came from the fact that it was grounded in an exhaustive inquiry into the family's process and patterns. "Some people thought the Milan approach was a way of outwitting the family," says Lynn Hoffman. "Whatever the family did was a maneuver and therefore the therapist was justified doing a maneuver right back. What those people missed, I think, was the heart of the approach, which was a way of developing a systemic mind and inquiring into the very basis of the family's life together.

The Team Splits

After years of close collaboration, the Milan team finally split up in 1979. Faced with a deluge of requests from therapists eager to learn their method, Cecchin and Boscolo decided to open their own institute and concentrate on training. Palazzoli and Prata, neither of whom needed to rely on their clinical work for income, chose to continue their research collaboration, but change its direction. Palazzoli seemed to feel she had gone as far as she could go with the paradoxical approach. She soon absorbed herself in developing an entirely different clinical method, one that she first described to American family therapists at a much anticipated 1982 conference featuring Palazzoli and two other well-known clinical innovators, Salvador Minuchin and Carl Whitaker. Expecting to hear her discuss paradox, the audience instead heard that, after a few sessions, she was giving the following prescription to the parents in every family she saw in her research project:

Keep everything about the session absolutely secret at home. Every now and then, start going out in the evenings before dinner. Nobody must be forewarned. Just leave a written note saying, "We won't be home tonight." If, when you come back, one of your children inquires where you've been, just answer calmly, "These things concern only the two of us." Moreover, each of you will keep a notebook, carefully hidden and out of the children's reach. In these notebooks each of you, separately, will register the date and describe the verbal and nonverbal behavior of each child, or other family member, which seems to be connected with the prescription you have followed. We recommend diligence in keeping these records because it's extremely impor tant that nothing be forgotten or omitted. Next time you will again come alone, with your notebooks, and read aloud what has happened in the meantime.

Although Carl Whitaker expressed his delight at Palazzoli's new approach to the "greased pig of schizophrenia," most of the audience at the conference were puzzled by her presentation. Was she saying that she had developed the ultimate intervention, a tool so magical that all other approaches were now irrelevant? Or was she presenting preliminary data of a highly specialized research project? Palazzoli seemed content to drop her bombshell and let others draw their own conclusions. It was left to Minuchin to warn the audience against adopting Palazzoli's "interesting research methodology as an everyday clinical tool."

Soon after the conference, Palazzoli and Prata ended their partnership and Palazzoli formed a new team with three younger colleagues, Anna Maria Sorrentino, Stefano Cirillo, and her youngest son, Matteo Selvini. The team also enlisted researcher Maurizio Viaro to analyze the team's interview techniques.

The new team soon became interested in the invariant prescription as a research device. Carefully analyzing their sessions and the observations parents were recording in their notebooks, Palazzoli's team began to see the prescription as a means of eliciting family patterns and comparing responses across families to a controlled clinical stimulus. They concluded that the very blueprint for schizophrenia and anorexia had emerged from their study.

Palazzoli now maintains that a single developmental process takes place in all families of anorectics and schizophrenics. It begins—where else—with a conflictual, stalemated relationship between the parental couple. Eventually, a child is drawn into the game, first as an interested observer and later as an active participant. What the child sees is that one parent appears to be more provocative than the other. According to Palazzoli, "He wrongly considers the actively provoking parent to be the winner and the passive one as the loser, and he takes sides with the 'loser.'"

The child then takes on a very ambitious project. He begins to display unusual, troublesome behavior that requires parental attention. But the message of the behavior is covertly directed at the parental "loser." It is a demonstration of how the winner can be defeated, as if the child is saying, "Watch me and see how to dominate." But then everything goes awry. Instead of understanding the child's message and joining with him, the loser sides with the other parent in disapproving of the child and even punishing him. The child feels misunderstood and utterly abandoned. Instead of becoming depressed, however, the parental "betrayal" challenges him to escalate his behavior. Says Palazzoli, "His competitiveness becomes unlimited. His unusual behavior having failed its purpose, he will now resort to crazy behavior in order to prevail at all costs. He will bring the winner down on his or her knees and show the loser what he, the child, is capable of doing." (Selvini, 1986) Finally, the family system stabilizes around the symptom and all members devise strategies to turn the situation to their own advantage. It is this grand model of "psychotic family games" that Palazzoli thinks may be the most lasting contribution of her research.

On the Edge

Palazzoli's latest work couldn't be more out of step with the political climate in American family therapy today. It seems oblivious to the impact that groups like the National Alliance for the Mentally Ill, an advocacy organization founded by the parents of schizophrenics, have had in sensitizing therapists to how people outside the profession react to theories which appear to blame client families. In this atmosphere, one could hardly imagine a more inflammatory label than Palazzoli's concept of dirty games. What's more, the field as a whole has become increasingly skeptical of anything that sounds like a miracle cure. As a result, Palazzoli's invariant prescription has been widely dismissed as a preposterous therapeutic gimmick As one family therapist put it, "Wouldn't it be horrible if the invariant prescription worked as well as Palazzoli says it does? I'd be afraid somebody would use it with me."

Nevertheless, some believe that rather than being out of step with the field, Palazzoli is addressing one of family therapy's glaring needs. "As a field, we are rich in interventions, but poor in theory," says Peggy Perm, Director of training at the Ackerman Institute. "What is most intriguing about Mara's latest work is her suggestions about the sequen tial development of coalitions in dysfunc tional families. I know some people think she has gone over the edge, but that always happens when some theorist moves away from the identifiable center."

The next few years will tell what impact Palazzoli's current work will have. She believes that the publication of her book about the invariant prescription, due out next year, will clear up her critics' misunderstandings of her research and encourage therapists to try her model. Right now, however, there seem to be few therapists around the world who have adopted the invariant prescription as a clinical tool. Peggy Penn thinks that's because "most clinicians regard it as too difficult to apply and don't have a team to support them in trying it."

Whatever the outcome of her current research, Palazzoli has already established herself as one of family therapy's most influential innovators. "Mara has made contributions that have endured and become part of the public domain of the field," says Salvador Minuchin. "Paradox, circular questioning, positive connota tion—these are no longer just her ideas. They are things that everybody uses."

"Mara is a discontinuous genius," says Lynn Hoffman. "Periodically she comes out of nowhere with brilliant new ideas that seem out of the context that shapes conventional thinking in the field. That's what makes her so important. She's dramatic and unconventional, and sometimes I don't agree with her. But I think she has done more for the field than almost anybody I know. I would hate to see anybody clip her wings."

This article originally appeared in the September/October 1987 issue of Psychotherapy Networker.


References

Anderson, C. M. (1986). The all-too-short trip from positive to negative connotation. Journal of Marital and Family Therapy. 12,351-354.

Selvini-Palazzoli, M., et al. (1978). Paradox and Counterparadox, New York: Jason Aronson.

Selvini, M. P. (1986). Towards a general model of psychotic family games. Journal of Marital and Family Therapy. 12, 339-349.

Simon, R. (1981). The trade secrets: An interview with Betty Carter. The Family Therapy Network Newsletter. 5, 6, 7-10.

I am indebted to Susanna Bullrich of Hahnemann University who served as translator during my visit to the Nuovo Centro per lo Studio della Famaglia and later translated the Italian transcript of the session with the Santini family, which is extensively quoted in this article.





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