Like the previous story, the metaphorical story “The People of Lensland” can be used for patients suffering from body dysmorphia, in particular anorexia. It can however also be used in relation to hypochondria and the exaggeration (or downplaying) of illness in order to help the unconscious set a more realistic benchmark for the assessment of symptoms.
The people of Lensland are born with binoculars in
front of their eyes. Most of them are born with binoculars which are the wrong
way round, and everything they see looks very small. Whenever they meet someone,
they might think, “Aren’t they a long way away!” “Aren’t they small!” or “Aren’t
they thin!” However a few people are born with binoculars which are the right
way round. Whenever they look down at themselves, they might think, “Aren’t I
long and wide!” The people of Lensland find it very hard to agree amongst
themselves. Yet once upon a time a woman living there made an incredible discovery…
The story “The Fat Woman and the Thin Woman” was developed while working with anorexic patients, and takes as its starting point the idea that even patients suffering from anorexia have a part of their personality which knows that they are underweight and which can engage in a conversation with the other part of their personality. The story is also based on the idea that the therapist should avoid representing the viewpoint “you are too thin”, and should instead represent the ambivalence between the outer world, which assumes that the patient is “too thin”, and the client’s inner world, which assumes that she is “too fat”. The task pursued in therapy is to initiate an inner dialogue between both viewpoints and parts of the personality, with the ultimate aim of negotiating a middle road and a “third way”.
There is not just one world, but two different worlds.
This must be the case, because we are not talking about the same world. We are
talking about different worlds.
The fat woman lives in the inner world. The fat woman
is not very popular. Everyone in the inner world despises her, and everyone in
the outer world refuses to believe that she exists. The thin woman lives in the
outer world. The thin woman is also not very popular, because everyone in the outer
world worries about her, and no one in the inner world believes in her. The fat
woman from the inner world does not believe in the thin woman from the outer world.
She can’t work out why the people she meets claim to meet the thin woman every
day. The thin woman from the outer world does not believe in the fat woman from
the inner world either, and she can’t work out why the person most affected by
all of this claims to see the fat woman every day. Who is right? Those who
believe in the fat woman, or those who believe in the thin woman?
Both the thin woman and the fat woman live in people’s
heads – but in different worlds. They live on different planets. Now that we
have entered the age of technology, visiting other planets is simply a question
of deciding on a means of transport. I can imagine boarding a special capsule
which would take me out of the inner world and over to the outer world for a
limited period of time. That might be quite pleasant, since I’d get rid of the
fat woman on the way there, and I’ve needed a break from her for a long time.
The price I’d have to pay when visiting the outer world is that I might meet
the thin woman, even though I don’t believe in her and perhaps don’t want to
believe in her. And apparently she doesn’t look too great, but who knows. I can
also imagine that at the same time as me, in exchange so to speak, a second spaceship
would launch off from the outer world and fly to the inner world for a holiday
in the fat women’s world. Then they’d know what it was like living with her day
after day, and would no longer deny her existence.
I wouldn’t go on this
journey very often – why bother? Later I will send the fat woman herself on a
journey to the thin woman, so that they can exchange experiences and learn from
each other. I want the fat woman to learn from the thin woman, and the others
want the thin woman to learn from the fat woman. I’ll stay at home and take a break
from the fat woman.
The case study “How to Handle Sexual Assault…” discusses the possibility of protecting oneself against sexual harassment.
A colleague recently called me for some advice. A female
friend of hers was being sexually harassed on a regular basis by a neighbour
who engaged in exhibitionistic behaviours towards her while he was in his
garden, and sometimes also made lewd comments on her figure and her clothes.
We discussed possible solutions together, and decided
that the police would probably not be much help in a case like this. In my
colleague’s opinion, the next time it happened her friend should look over and
comment wearily, “Not exactly well endowed, are you?” I for my part thought that
the woman should keep a pile of water bombs made from balloons filled with
tomato juice ready in her garden. Alternatively, a blowpipe filled with cherry
pits should also do the trick – simply aim at his manhood, and one hard puff! A
friend who was listening in on the conversation suggested that the woman should
carry a digital camera around with her and take a photo the next time it
happened. Even if the photo didn’t show much, the neighbour would be in a very
awkward position as soon as the flash had gone off – not only because it might
be shown to the police, but also because he would have to live in permanent
fear from that moment onwards that the offending image might be posted on the
Internet, “liked” by friends and neighbours and go viral. “You’d be better off
with a video,” suggested someone else. “Then you’d have sound too!”
My only fear is that these brilliant ideas were never
used; once the woman had these tricks up her sleeve, her behaviour would have
altered and the neighbour would probably have intuitively stopped the
The story “Snail Race” can be used with patients suffering from various sexual dysfunctions, although it is recommended that the text be adapted to the relevant situation. The accumulation of suggestions through semantic field associations and ambiguity is unmistakable.
The snails are having a race. A group of birds who are
watching are open-mouthed – or rather open-beaked – at the length of time taken
by these moist creatures to make progress, and how slowly they expel slime as
they moisten the ground over which they glide. They make steady progress, but
it takes them a very long time to reach their goal. Yet a snail race is enormous
fun for those who know how to take their time. There’s a lot to see; how the
snails strain forward to make progress! How they straighten their smooth, solid
feelers, and stretch them out towards their goal! How the sides of their body move
with a wave-like motion in order to push them onwards! Someone once said that
if only we could learn to experience slowness, we would see how snails really
lean into the corners. And it’s true; anyone who wants the snails to go faster
can simply experience everything more slowly. Then a snail race will be just
the right place for him, and he will see how fast they are. When the snails race
each other, they are full of movement. From their feelers to their slime glands
and from their mouth to their tail, everything moves forward. They are experts
at rationing their strength. And when the time comes, they accelerate for one
final spurt on the home stretch until they finally cross the finishing line,
panting with exertion.
Recently I stayed at a friend’s house. “You snored all
night long. It woke me up and I couldn’t get back to sleep for over an hour,”
she told me the following morning. “Wake me up if it happens again tonight,” I
said. “Did I snore last night?” I asked the morning after, although I had slept
all night without being woken. “No, not at all. I don’t understand why,” she
answered. “I told myself not to lie on my back at any point during the night,
and instead only to move from my left side to my right side.”
The story “Alarm Clock with a Snooze Button” represents a basic intervention for handing over control of sleep from the conscious to the unconscious, and for suggesting that it is safe to do so because the unconscious knows that it can easily handle the task. The alarm clock story can be used for patients who find it difficult to fall asleep or stay asleep, for patients who repeatedly oversleep and for patients who are worried about waking up too early from an anaesthetic or not waking up at all. It can also be used for all sleep disorders which can be prevented by waking up in time, such as bedwetting, sleep apnoea and snoring, as well as for nightmares. The story embodies the basic suggestion that control is retained even during sleep, and can therefore be used to make it clear to patients with a compulsive and controlling personality that they can stay relaxed while remaining fully in control.
“My body has an internal alarm clock,” one friend said
to another. “Before going to sleep, I tell myself; ‘Tomorrow morning I’ll wake
up at ten past six.’ And then the next morning I’ll wake up at exactly ten past
six. Yet recently I woke up at ten past six and did not get straight out of
bed. I went back to sleep again and overslept.” “That could never happen to me,”
answered his friend. “My internal alarm clock has a snooze button. Before going
to sleep, I tell myself; ‘Tomorrow morning I’ll wake up at ten past six, and
then I’ll wake up every five minutes after that.’”
The case study “Soiled Underwear Again” demonstrates a symptom prescription in the form of homework to carry out a ritual. This paradoxical intervention follows the Milan tradition of systemic family therapy.
Paul was six years old. Almost every day he waited
until he was alone, found a quiet spot in the house where he could hide in
peace and take his time, and then soiled his underwear. His excuses were many
and varied, and often he had none at all. He only used the toilet reluctantly
and under protest. None of the doctors who had examined him had found any
problems. His mother had tried both being patient and being strict.
When I met Paul and his mother, I asked him whether he
thought he could deliberately soil himself on a particular day. He responded in
the affirmative, both to this question and to the question of whether he could
deliberately not soil himself on a particular day.
So I came to an
agreement with Paul and his mother that he should deliberately soil himself,
today if possible, and that his mother should allow him to do so. Tomorrow
could then be the day when he deliberately did the opposite. Or he could soil
himself today and tomorrow, with his mother’s express permission; what mattered
was that he had soiled himself at least once before our next meeting. He could
tell his mother beforehand or afterwards, or simply let her work it out for
herself. And I discussed the details with Paul; on how many days of the
following week he would soil himself, and on how many he would not. His mother
offered to note down every time when he soiled himself on the calendar so that
I could see whether he had done his job properly. The young boy protested that
he would never soil himself again. I made a point of telling him that it was
much too early to be thinking about that. I implored him to try and soil
himself at least one more time
The case study “Continent Eyes” highlights the widespread phenomenon of conversion disorders. Simply alerting clients to the possible existence of a conversion disorder may cure it; alternatively, speculation that the incontinence might be a conversion symptom can also cure disorders which can be influenced through suggestion, presumably through a type of placebo effect.
A man once came to see me because he was still suffering
from continence problems after undergoing prostate surgery, even though his
doctors had told him that there was no longer any organic cause for his
incontinence. During his third therapy session, he told me that he had recently
cried for the first time in years when a doctor told him that all of his
symptoms were perfectly normal, and that he would in all likelihood become
“Have you ever heard of a conversion symptom?” I asked
him. “Maybe your excretion organs are incontinent because your eyes are
continent. Your bladder has taken on the role of your eyes or vice versa,
depending on your point of view. I wouldn’t be at all surprised if you became
incontinent in an unexpected way in the near future.”
When I next saw the man, he said: “I don’t know whether
it’s because of what we discussed, but now I only need to use one third as many
incontinence pads to stay dry.”
The story “Shifting Interests” makes it clear that people often have hidden skills which remain unknown to their nearest and dearest, sometimes for decades. It is impossible for us to tell what another person cannot do or does not know, and we are only aware of a small fragment of what he can do and does know. This is particularly true when working with children with behavioural problems or persons with mental health problems or disabilities.
After spending a long time in a coma, Dennis returned
to the land of the living with reduced mental functions. He had forgotten many
things, and was apathetic about most of the rest. Yet he often pointed to the
sky and said, “Look, an F-14 Tomcat plane!” or “Wow, an Apache helicopter!” and
described the engine types, performance, carrying capacity, cockpit equipment,
crew and weapons of the aircraft he saw flying past. “He fought in the Korean
War,” said his wife. “But I had no idea he still remembered all of this. We’ve
been married for 30 years, and he’s never shown any interest in aircraft.”
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