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 continent again.

“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.”

The case study “Memory” illustrates a procedure for learning to remember things again. Single associative connections are useless if they are disrupted; instead, a larger network of links is communicated so that individual functioning associative connections within this network can help to reactivate others or reconstruct the context.

“After my stroke,” he said, “people knew me but I no longer knew them. ‘I’m Peter!’ one of them said. ‘Which Peter?’ I replied. ‘Don’t you remember me? We went to school together, we did our apprenticeships together, we worked side by side…’, ‘I’m sorry, I don’t remember you,’ I said. ‘But we went on holiday together,’ he continued, ‘and you gave my daughter Julia this funny teapot.’ ‘Are you Julia’s father?’ I asked with surprise. ‘He was called Peter and went to school with me. Is that you?’”

The story “After the Storm”, like the following three stories, is an intervention which can help a patient to recover missing words and skills if he or she has the necessary level of understanding. The stories refer implicitly to the fact that the relevant information is not lost in the brain but merely inaccessible, and can therefore be found again.

The storm has wrought havoc. Fallen trees are strewn throughout the forest. Their trunks are blocking the paths and roads. No traveller can pass. Yet the time after the storm is the time when the lumberjacks start work. They use their saws to open up the paths, move the blockages and clear the roads, starting at the outer edge of the forest and moving right to its very interior.

The case study “Pantomime” shows what communication of this kind might look like and the effects it can have. Interventions of this kind can also be used to utilise the behaviour of a person suffering from mutism for the purpose of establishing

“Hello. My name is….” he began. “She can’t talk,” the nurse told him. “She’s had a stroke…” The young patient’s helpless gestures told him that she could not even understand what he was saying, with the exception of a few words to which she replied with a nod or a shake of the head. How can one communicate in such a situation? He used gestures to outline a steep staircase with high steps in the air in front of him. He sighed; too steep, too high! He shook his head in disappointment. Then he gestured with his hands to indicate a staircase with shallow steps, and he walked up the entire staircase with his fingers. The woman watched attentively and nodded. He used hand gestures to outline a high mountain in the air. A climber (represented by two fingers) wanted to reach the top, but kept falling back down. Then he found a less steep route which zigzagged upwards with many twists and turns, and he followed this path to the top. The woman’s eyes began to light up, and the pantomime continued. “Never losing sight of your goal” and “strength” were the next ideas to be expressed. The movements of a long-distance runner and a raised fist encouraged her to persevere and develop a fighting spirit. A clock with a ticking hand told her that it would take time. He continued the game of charades by placing his hands to the side of his head and pretending to fall asleep and wake up, fall asleep and wake up, over and over again until she had reached her goal, which he demonstrated by shading his eyes with his hand, peering out and pointing into the distance. He used his hands, his feet and his whole body to demonstrate how her children would support her on the left and her parents on the right, and how they would all complete the long journey together. He stretched his fist up to the sky once again; she would have to put all her strength into the fight. Three days later he came back to visit the patient again, and the patient in the neighbouring bed spoke in her place. “She’s been here for four weeks now, and before you came she wasn’t improving at all. But over the past three days she’s made enormous progress.” He spoke to the patient, and this time she understood every word. Then he said goodbye. “Goodbye,” she said. That was the first word she learned to say again.

The city of Chelm once became the breeding ground for a strange epidemic, and this is how it happened…

You will the story Morbus Feivel in Hammel’s “Handbook of Therapeutic Storytelling” (Routledge 2019) on page 38…

The story “Mrs Flow” personifies therapeutic goals and resources in a fictional character, and at the same time distracts the patient from any stressful real-life experiences which might block the work.

Mrs Flow builds staircases. She builds wooden staircases, marble staircases, and even glass and rubber staircases and spiral staircases. She builds staircases which go up and staircases which go down, and she has invented a new type of staircase which goes up and down and up and down and up and down. She has invented a staircase which can be folded up, a staircase which can be pushed together and a staircase which is completely flat. I don’t quite understand how it works, but experts have assured me that it really does exist – a completely flat staircase. Mrs Flow also works together with a colleague to build escalators. The interesting thing about these escalators is that they start off as a not-staircase, gradually turn into a staircase, become less and less of a staircase and then end up as a not-staircase. When I was a child, I always wondered where escalators come from and go to. Once I saw an escalator at an airport without any steps at all. You could build a hill into a step-free escalator of this kind so that it changed from a flat treadmill into an escalator going up, then an escalator going down, and then a flat treadmill again, maybe with a higher level in between – up the staircase, flat for a while and then down the staircase, or the same thing but going down instead of up. The luggage carousels at the airport are just like flat staircases which go around lots of corners. Some of them bring the luggage up a steep slope, a luggage staircase or a luggage lift first before it starts going around the carousel. There’s a great deal of flexibility when it comes to designing these staircases and luggage carousels, and Mrs Flow is an expert on the matter.

The city of Chelm once became the breeding ground for a strange epidemic, and this is how it happened. So many people in the city were falling ill that Doctor Feivel thought to himself how much quicker and easier it would be to stop examining the city’s residents to find out what illness they were suffering from, and instead to find out who had been infected by health and what kind of health it was.

He diagnosed healthy bones in a patient who had no broken legs, a healthy heart in another patient, a severe case of healthy skin in a third and so on. When Schlemihl came to see him, he diagnosed uninfl amed health of the gums. When Schlemihl asked him what he meant, the doctor – who had already started examining his next patient – muttered, “Morbus Feivel, advanced stage of severity.”

Schlemihl did not really understand what he meant, but did not wish to admit his ignorance and so did not query the diagnosis. When he arrived home and his wife asked him what the doctor had said, he answered curtly, “Infectious health.”

Schlemihl’s wife wondered how it could be possible that she and the children still had a cold when they lived in such close quarters with Schlemihl. When she asked Doctor Feivel, he explained, “It’s because of the incubation time. The proper symptoms only appear a few days after transmission of an infection of this kind.”

And by the next day Schlemihl’s wife and children were indeed feeling much better. “We’re suffering from infectious health,” they explained to their neighbours. “We caught it from Schlemihl.” The neighbours were also infected with health over the next few days, and soon Morbus Feivel had spread like wildfi re throughout the entire city. Before long the residents of surrounding villages came to infect themselves with Schlemihl’s epidemic, and eventually the entire country was infected with it – at any rate according to Schlemihl’s version of the story.

(Stefan Hammel, Handbook of Therapeutic Storytelling, p. 38-39)

I recently visited my sister and her family.

Right at the start of my visit I took a drink of water out of a glass which was standing in front of me.

“ You didn’t drink out of that, did you?” asked my sister. “That glass belongs to Luise, and she’s highly contagious.”

I bent over the glass and spat the following words into it: “Make sure you don’t catch the Stefan disease!”

Then I drank all the water in the glass. And nothing else happened – at any rate not to me.

(Stefan Hammel, Handbook of Therapeutic Storytelling, p. 39-40)