The Bypass Operation: An Approach to Feeding Problems in Young Children

Michael White, David Epston, Dean Lobovits, & Jennifer Freeman

 

Excerpt from Playful Appraoches to Serious Problems, W.W. Norton , 1997.

Our theoretical foray having come to its end, we offer an extended example of Michael White and David Epston’s playful approach to feeding problems with young children. We hope to illustrate:

• how the sociocultural context of both parent-blaming and the problem of the child are externalized;
• how a playful approach “bypasses” the problem and parent-blaming and encourages the creative experimentation of children and their families;
• how the inadvertent participation of parents in the “life” of the problem is made available for their review and critique in a nonpathologizing manner and with an attitude of respect for their best intentions and efforts.

The following description of the “bypass” approach is based on an unpublished manuscript written by Michael and David about ten years ago. We were concerned that it would be left to collect more dust and eventually become lost to the passage of time. This would be unfortunate, since some ideas that we believe to be precious would be forfeited. With Michael’s agreement, we have dusted it off and reworked it some for this volume.

This approach evolved from Michael and David’s being consulted by families on numerous occasions about feeding problems of young children–problems such as refusal of food and inadequate nutritional intake. By the time the parents met Michael and David, these feeding problems often had out-survived various professional interventions and folk remedies.

Parents reported histories of (a) continuing reflux and gastric disorders, (b) childhood illnesses or medications that had suppressed the appetite, and (c) diminishing food intake and body weight. In all of the initial consultations with these families, it was discovered that there was a history of attempts to address the problem through medical workups and through behavioral/psychological practices. Despite this, the feeding problems had not only persisted but worsened over time.

Although there were various presentations of the feeding problems, David and Michael recognized some common features in their histories. They observed that family members, particularly the parents, were engaged in all kinds of measures to try to get their child to accept food. The parents had usually internalized strong cultural assumptions and social expectations that had them attributing fault to themselves. They believed, sometimes secretly so, that the feeding problem reflected their inadequacy and failure as parents, and they experienced considerable guilt on this account. The children who were the objects of these “helping” efforts had little or no sense of themselves as agents who could effectively act in relation to matters that concerned their own lives.

This central engagement of parents in measures to try to feed their children is totally understandable. If children’s nutritional intake is minimal and they are suffering for this, parents will take increasing responsibility in their efforts to modify this nutritional intake. However, as an outcome of this development, children often experience less competence at recognizing their own appetite and assume less responsibility for satisfying it, gradually becoming less able to care for their nutritional needs. David and Michael considered that these developments were reinforced by a socioculturally informed vicious cycle that engages all family members in inadvertent participation in the “life” of the problem. Family members become increasingly organized around the problem, binding themselves together in a repetitive and self-defeating cycle. The real effects of this on all concerned are self-blame, desperation, and burnout.

When the situation became sufficiently desperate for the parents of these children, they all consulted health professionals about the feeding failure. Although most felt shame as parents at this point, this mostly went unrecognized and was not subsequently addressed. The outcome for the parents was a sense of “being judged wanting,” regardless of whether or not this was the intention of the health professionals who were initially consulted (some of these parents had been explicitly and powerfully pathologized in their interactions with “mental health” professionals, who had ferreted out exotic accounts of parental responsibility for the etiology of the feeding problem, thereby confirming the parents’ worse fears). In response to this sense of shame, and to the explicit expectations and exhortations of neighbors, friends, and relatives, most of these parents had lost touch with the successful stories of their own histories and had withdrawn considerably from their social networks.

Upon meeting with these families and reviewing the various forces at work that were in league with the maintenance of the feeding problems and with the construction of the stories of parental failure, Michael and David found parents and children enthusiastic to step into a novel solution. In response, and with the encouragement of these parents and children, Michael and David developed an approach to feeding problems that they call the bypass operation.

Moratorium on guilt

The bypass approach begins with a moratorium on guilt. It is important for a therapist to encourage a moratorium on guilt and self-blame in order to provide relief for the parents, (particularly for mothers). This frees parents of a burden that can be paralyzing to them, and readies them to engage in the exploration of, and participation in, novel approaches to resolving their children’s feeding problems. David and Michael have developed a number of ways to initiate this moratorium.

One tack is to predict or preempt the guilt and self-blame of family members through a series of seemingly presumptuous questions generated by information collected from other families. A prologue provides a rationale for the questions. The therapist might begin: “Because I have been involved in many consultations around feeding problems like yours, I have collected a wide range of self-accusations from your predecessors. Can you tell me which, if any, you have been subscribing to? Please listen to them carefully so you can determine which fit your experience. I would also be interested to discover which you have managed to avoid, and whether you could add some original self-accusations to this list that would usefully expand the collection.” The therapist then works through the list. For example:

•  “Have you accused yourself of breastfeeding your child for too long?”
•  “Have you accused yourself of not breastfeeding your child long enough?”
•  “Have you accused yourself of having a child too soon?”
•  “Have you accused yourself of having a child too late?”
•  “Have you accused yourself of being too close to your child?”
•  “Have you accused yourself of not being close enough to your child?”
•   “Have you accused yourself of contributing to this feeding problem through ambivalent feelings?”
•   “Have you accused yourself of contributing to this feeding problem through a lack of ambivalent feelings and through total acceptance of your child?”
•   “Have you accused yourself of going back to paid work too early?”
•   “Have you accused yourself for experiencing insecurity in your decision about not going back to paid work?”
•   “Have you accused yourselves of not being united enough as a couple?”
•   “Have you accused yourselves of not being independent enough in your relationship with each other?”

And so on.

This provides just a small sample of the options for self-accusation. There are, in fact, many creative and unique examples of self-accusation. The possibilities for this seem limitless (although most parents can identify with some or all of the above). Parents are usually relieved to have their self-accusations not only acknowledged but subtly undermined at the same time. With the use of irony, the therapist and parents can join in the pathos of suffering from taking into themselves the freely available guilt and blame that circulates around parenting, particularly around mothering, in our culture.

It is also possible to engage families in selecting facts that more directly contradict specific self-accusations, for example those that are informed by “mother-blaming.”.To accomplish this, questions are asked of family members that give rise to stories of events that undermine parents’ problem-saturated definitions of themselves and their relationships. Attending to such stories leads to the formulation of further questions that engage family members in detailed conversations about how they have, on these occasions, managed to escape the influence of the powerful self-accusations featured in problem-saturated definitions of themselves as parents. Also, this review puts therapist and parents in touch with various self-accusations that they could have embraced but have managed to avoid so doing.

For example, when Michael was asking Elise and Brian which of these self-accusations were familiar to them and which were not, it became evident that, in spite of their familiarity with these accusations, they had managed to resist the trap of pathologizing their relationship with each other as parents. He asked: How was it that they had managed to avoid this despite the despair and desperation they had gone through? What did this achievement reflect about their relationship with each other? In the ensuing reauthoring conversation, Elise and Brian found themselves redescribing their relationship through the identification of its “solidarity,” its capacity for “understanding,” and according to the important values that provided a foundation for this. As this conversation progressed, and as Elise and Brian experienced the honoring of their relationship in the therapeutic context, they ceased to be so powerfully under the thrall of many of their self-accusations and their sense of failure and hopelessness was attenuated.

Challenging isolation and social vulnerability

Many parents become increasingly isolated in response to unsolicited and conflicting advice offered by friends and strangers. As their children look quite sickly, they often feel obliged to defend themselves against overt or covert accusations of “bad mothering,” “child abuse,” etc. When they tire of this, they often withdraw from their social networks and isolate themselves from extended family, friends, and acquaintances. To disrupt this, David and Michael found providing the mother (parents) with a “To Whom It May Concern” letter to be very effective. For example:

 

 

Below is an excerpt from an interview that David conducted with these parents to explore the effects of the letter. It shows not only the ways the letter was used to circumvent guilt and blame but also the pain of isolation.

Naming the child’s inner strength

Along with or subsequent to the work with parents described above, the therapist playfully discovers and engages the child’s strength of purpose and responsibility to eat. This type of discovery is usually achieved as an outcome of an externalizing conversation in which there is a detailed exploration of the effects of the “eating problem” on the child’s life:

• “What does this eating problem talk the child into about herself?”
• “How does it leave her feeling a lot of the time?”
• “How does it interfere with her physical abilities?”
• “Does it sap her energy?”
• “Does it try to interfere in making friends?”
• “Does it plan to throw the spanner in the works of her connection with mom and dad?”
• “Has it been attempting to ruin her hopes for having more fun?”
• “Has it been trying to wreck her chances of going to playschool or kindergarten, or maybe sleeping over at a friend’s house?”

This is just a small sample of some of the questions that might be asked. It is important that they be rendered in an age-appropriate form. With very young children, parents can assist in engaging them in such conversations.

In the course of these externalizing conversations, unique outcomes or exceptions soon become apparent in various domains of the child’s life. Eating problems are never totally successful in their attempts to dominate children’s lives. There are always going to be examples of the child’s strength of purpose prevailing in certain situations, and there will even be examples of physical prowess despite the eating problem’s efforts to entirely sap the child’s strength. For example, children are often described by their parents as “strong willed” in many respects, including their refusal of food. When this occurs, the therapist expresses curiosity about the whereabouts of the child’s “strength” when it comes to solving the problem. Then therapist and the family may jointly puzzle over this anomaly.

Examples of the child’s strength of purpose are pooled together, and an inquiry is begun as to the nature of these:

• “Where did the strength come from?”
• “What sort of strength is it?”
• “What would be a good name for this strength?”

Various identities are evoked in the naming of this strength. With young children these are invariably animal identities: “Tasmanian Devil Strength,” “Elephant Strength,” “Whale Strength,” and so on. But for some reason, with these children, more often than not, the strength is named “Tiger Strength.”

The naming of the strength is this way provides options for therapist-generated questions that shape extended narratives on the child’s “tigerishness” (or “Tasmanian devilishness,” or whatever) and the historical importance of this to his or her survival. As these narratives unfold through the engagement of the parents and the child, the problem-saturated story of the child’s life and identity is overshadowed. This sets the scene for the child to develop a stronger alliance with her tiger, and to support the tiger’s efforts to rid her life of the feeding problem. This also sets the scene for the institution of a far more playful approach to this deadly serious problem, which is a very substantial relief to parents who have suffered so much anxiety and who have experienced their efforts to resolve the problem to be just so much fruitless work.

Whenever we want to call on the young person’s strength of purpose we mention its “tigerishness.” Questions are asked of the young person that relate to his or her strength of purpose through the tiger metaphor:

• “Do you think you have a tiger inside of you that makes you so strong?”
• “Are you pleased to discover you’ve got a tiger inside of you?”
• “How did you get such a tiger inside of you?”
• “Have you tamed the tiger inside of you or does it run wild?”
• “When I first met you, do you think I would have been able to guess that you had tamed the tiger inside of you?”
• (To the parents) “Had either of you realized this or is it news to both of you too?”

The achievement of a moratorium on self-accusations and associated guilt, the erosion of the parental sense of isolation and social vulnerability, the reauthoring conversations that parents and child have stepped into, and the specific naming of the child’s strength ready everyone for the bypass operation.

Applying for the bypass operation

Many families have a history of having once been playful together. Even if they have not been playful before, they usually relish the possibility. After a conversation about this past experience or future desire, the therapist highlights the family’s expectations of either the return of the long-lost playfulness or the delightful emergence of such an unfamiliar state. In a lighthearted way, the therapist then introduces the application for the bypass operation. The application consists of questions to ratify a family’s readiness to proceed playfully. Application questions articulate the family’s two options: to further cooperate with the seriousness of the problem or to oppose it and engage in a playful solution.

We provide some examples of these questions here. The responses to these questions invariably constitute a turning point for parents and for children.

Application questions for parents:

• “Right now, do you feel further inclined to explore theories about your culpability for the eating problem, or do you think that now would be the right time to invest your energies in a solution that is entirely different from what has been attempted so far?”
• “In view of what you have been through, do you think it would be wise to continue some of the heavy problem-solving tactics that you have been introduced to in the history of this problem, or would you be more predisposed to a lighter and playful approach to solving this problem if this were available to you, one that is more in line with some of the more fun ways that you can be together as a family?”

Questions for the young person around his/her relationship with “the tiger inside of you”:

•  “Thank you for teaching me about your tiger strength. What is it that makes tigers strong? Does feeding tigers make them strong, or does starving them make them strong?”
• “If feeding makes tigers strong, do you think you should get in the way of your tiger, or do you think you should step aside and let your tiger feed itself?”
• “If your tiger is your friend, do you think you ought to feed it or starve it?”
• “Do you think you should get in the road of your tiger at meal times, or do you think it would be best to let it past so that it can eat?”

In response to these application questions, parents invariably opt to break from further investigations of culpability and burdensome approaches to the eating problem and express a strong preference for lighter and more playful options. Children decide that it would only be fair to let their tigers feed themselves. They usually express a keenness to step aside to let their tigers feed, so long as this doesn’t directly implicate them in eating. Now the family is ready for the operation.

The bypass operation

The bypass operation takes the form of a playful eating ritual. An odd days/even days schedule is drawn up, and parents and children are informed that on every second day only the tiger is to attend mealtimes. On these days the child will make herself scarce so that she can be true to her agreement not to interrupt the feeding of the tiger. On the interim days, the child can attend the meal table as usual, but without any expectation that she will eat.

Parents are asked to make a tiger costume that the child is to wear on tiger feeding days only. After discussing with us some of the options for the development of such costumes, they usually put together wonderful creations. A tigerish persona is brought to life by the introduction of tiger apparel, tiger practice, tiger adventures, tiger menus, etc. Some examples are tiger tails fabricated of plaited yellow and black wool, cut-out paper bags for tiger heads and screen printed tiger t-shirts. A tiger menu is developed with the help of the child, who is assisted in this task by the parents. Because tigers are “not fussy eaters,” the menu is usually selected from a wide range of foods rather from an exacting dietary regime.

Parents are also asked to create a “Tiger Album.” The tiger menu can be incorporated in this album, as well as details of different tigerish feats engaged in by the tiger on its feeding days. These details can include photographs that capture on film tigerish stealth, endurance, and vigor. The parents and the child can also go in search of tigerish memorabilia and paraphernalia, and this can also be included in the album. It is recommended that this album be brought to the next meeting to be shared with the therapist.

The costumes, albums and other paraphernalia encourage a playful ambiance, in contrast to the spirit of deadly seriousness that has pervaded previous efforts to modify the child’s eating behavior. This further contributes to a suspension of the parents’ anxiety in relation to the child’s nutrition. In this approach, the introduction of the tigerish persona makes it possible to bypass the requirement that the child eat or, for that matter, that she have an appetite. The appetite is identified with the tiger, not the child. This externalization of and objectifying of the child’s appetite also make it possible for parents and children to bypass their customary anxious interactions in relation to food: It makes it possible for them to unite in a cooperative effort, one that is based on a shared concern for the tiger’s adequate nourishment, instead of being pitted against each other in their effort to solve a vexing problem that has everyone at a loss.

Case examples

The bypassing approach is illustrated by two case stories. In the first the therapist, Michael White, follows the above protocol. In the second, David Epston and his co-therapist Phyllis Brock modify the protocol when the family makes a serendipitous and creative suggestion.

Fred

Fred, four years of age, a small, thin boy with poor speech development, was distinctly pale and had large black rings under his eyes. He had been referred to Michael by a pediatrician who had exhausted numerous conventional avenues to ameliorate Fred’s self-starvation and was now very concerned about significant growth hormone deficiency. The conventional avenues had included several hospitalizations, and various behavioral programs.

Fred had experienced poor health from ten months of age after developing a gastric infection, one that was initially misdiagnosed. As a result, Fred became seriously ill and required emergency admission to the intensive care ward of a city hospital. Since Fred’s family lived in a remote area, he had to be transported to the hospital in an air-ambulance. Unfortunately, because this ambulance carried several intensive care specialists, there was no room for either parent to accompany Fred. The parents set out for the city by road, but the breakdown of their car en route further delayed their reunion with Fred, at a time when he most needed them.

It was touch and go for Fred for a while, but he then began to pull through, and he was transferred to a general ward. Soon after his arrival there, he was inadvertently fed a formula that he was known to be allergic to, and his response to this necessitated a transfer back to the intensive care ward. From that point on, it appears that Fred began to associate illness, nausea, and trauma (which included separation from this parents) with the ingestion of food and fluids, which he began to refuse.

Over the next twelve months or so he developed into a very “finicky” eater, and his parents became increasingly concerned about his growth and development, which was clearly delayed. Further investigations were undertaken, but no untoward medical factors were identified. Subsequent to this, various behavioral programs were instituted, but to no avail. Two more years passed without any relief, and with Fred’s parents becoming increasingly desperate about his meager diet and about his future. Fred was getting more and more frail.

At the first interview, the parents, Allan and Joan, tearfully filled Michael in on the history of the problem. They had little hope that further consultations would make a scrap of difference, but they did not know what else to do. They had “turned over every stone they could think of.” Now they felt fatigued and shattered. They were becoming increasingly isolated from parents in their community who had healthy children and were all too ready to hand out advice. For this same reason, they had also significantly withdrawn from their families of origin. Joan and Allan’s account of themselves as failed parents contributed to an acute social vulnerability. They both felt that they had no where left to turn. Their sense of desolation was tangible in the consulting room.

Michael speculated about the sort of conclusions they might have reached about their culpability for the problem and about their identities, not just as parents, but also as people. Joan and Allan seemed surprised to hear this. Michael then rose and excused himself, returning a minute or two later to read, and to ask them about, a list of self-accusations he had compiled in his meetings with other parents who had struggled with similar vexing circumstances. Now Allan and Joan were crying again. Michael waited, and then found a space in which to ask what was happening for them. The response took some time in the coming. Allan and Joan said that these tears felt like tears of relief, an experience that they had longed for. Suddenly they didn’t feel quite so alone; others had been where they were.

Through further exploration of the self-accusations, it was determined that four of the list of thirteen that had not occurred to Joan and Allan. This provided a point of entry to a reauthoring conversation that powerfully challenged their deficit-saturated accounts of their identities as parents and as people in a more general sense. In this conversation, both parents visibly separated from a sense of desolation and hopelessness. And they experienced an occasional flicker of pleasure as these alternative stories of their lives began to unravel.

Joan and Allan’s responses to the application questions were unequivocal. They were ready to commit themselves to the bypass operation. In the externalizing conversation that followed, Fred was quick to identify his tiger strength (his tigers had swum all the way from a far-off country), although Michael had to depend on Joan and Allan’s interpretations of Fred’s speech to understand his responses. “Did Fred know that sometimes when boys and girls eat they feel sick?” Fred nodded his head vigorously. “Did Fred know that when tigers eat they never feel sick? Lots of children do know this.” In response to these questions, Fred looked at this mother, then his father, and suddenly realized that he was familiar with this fact. And yes, Fred was prepared to stand aside to let his tigers eat so that they could become big and strong and ride bicycles and go fishing.

An odd days/even days schedule was drawn up, plans for the creation of a realistic tiger suit were discussed, a tiger menu was prepared, a story about what the tiger had planned was elicited from Fred with his parents’ assistance, and the “ins and the outs” of the approach were discussed. Fred and his parents entered into the discussion with excitement and a sense of fun. Michael discovered that they were actually very humorous people. The family then departed for home, via the zoo. This was to give Fred a further opportunity to become acquainted with tigers and to provide Allan and Joan with a jump-start on the album project–they could photograph some tigers and these could be pasted in the album alongside Fred’s story about his own tiger’s plans to grow big and strong.

The family returned for a second appointment two weeks later. Fred already looked like a different child. The black rings under his eyes had disappeared and the color had returned to his face. His parents reported that he had done what he said he would; that is, he had been standing aside to let his tiger feed. And they had all been stunned by the adventuresome nature of the tiger’s eating habits. Fred had almost “gone over the top,” in that on the tiger’s “off days” he had been lending a hand by putting some food in his mouth and the tiger had been “coming and eating it.” Fred proudly showed Michael his tiger album. It was an extraordinary work that plotted out an alternative narrative of competence and self-sustenance. Fred then donned his tiger suit. Michael got frightened, so the tiger turned into Fred again and reassured him that he wasn’t at risk. Joan and Allan joined in the thickening of the alternative narrative with obvious delight and relief.

A third session was scheduled a month later. At this meeting, Michael found that the progress had been maintained despite the fact that Fred had endured a viral infection during the interval between sessions. Fred had started to ride a bicycle, one that he had been too weak to pedal just six weeks earlier. He was now playing with other children, and there was a marked improvement in his speech. Allan and Joan talked about what it was like to “feel like a real father and a real mother to Fred again,” and about how they were all getting out more, re-engaging with friends and family (who for the most part were supportive of Fred and his parents in acknowledging and reinforcing the spirit of the bypassing approach).

Michael met with this family two more times and then undertook a follow-up eighteen months later. It was a great reunion. Fred had become a healthy and adventurous young man. His tiger now rarely visited during meals. Fred had mostly taken over responsibilities for his own nutrition. Allan and Joan agreed that they were all “more into life.”

Nick

Nick was six and a half when he arrived at the Leslie Centre along with his parents and three-year-old sister Olivia, to meet with Phyllis Brock and David Epston. Phyllis Brock interviewed the family; David Epston was an observer and reflector.

By comparison with Olivia, Nick was wan and looked worn-out and exhausted. Despite the attractions of the playroom, he settled into his chair, resting his head on his shoulder; he was oddly immobile.

Mr. and Mrs. Foster provided David and Phyllis with an account of the problem. Up until eighteen months of age, Nick ate well, so much so, in fact, that Mrs. Foster, formerly a pediatric nurse, was reassured that he was faring well against the well-known statistical profile. Then, suddenly and for no apparent reason, Nick started refusing a balanced diet. He gradually restricted himself to white bread and jam sandwiches. This was relieved only by the occasional apple or raisin. At the time, the Fosters didn’t seek help outside their family and friends, hoping that Nick would “grow out of it.” Their dismay increased over time as he grew into his stringent regime rather than out of it. Fearing that he wouldn’t be able to withstand the physical and intellectual demands of primary school, the family consulted a pediatrician when Nick turned five. They were reassured that, despite his low weight, he was in no danger. He was prescribed an appetite stimulant and “something else that made him a bit sleepy.”

Although Nick gained two pounds after this treatment, his diet was still restricted–he merely ate more bread and jam. The Fosters decided to discontinue his medications. Their concerns increased as Nick became more vulnerable to minor illnesses, was unable to participate in childhood games, and frequently retired to bed before 5 P.M.

By the time they arrived at the Leslie Centre, Nick’s parents felt they had exhausted every avenue to the problem’s solution, “from bribery to battle.” In fact, David noticed a penchant for military metaphors, such as “struggle,” “battle,” “fight,” and “warfare.” Mrs. Foster felt more defeated than Mr. Foster, as she “served more in the front lines.” A shift-worker, Mr. Foster was not often present at mealtimes.

Periodically, Mrs. Foster would challenge Nick and “he would go to bed with nothing to eat for three nights.” “Well,” she explained, “then he couldn’t go to school, so back to sandwiches. He won another round.” Attempts such as this would be followed by another period of appeasement, until her determination to “win a round” returned and she would try again. The Fosters had become so desperate that they took the advice of a friend and sought referral to the Leslie Centre.

The therapists explored Mr. and Mrs. Foster’s susceptibility to self-accusation by reading some of the post-treatment commentaries of other families who had come to the agency with feeding problems. These commentaries focused on how other parents had freed themselves from guilt and blame. The Fosters sought to join them.

By the end of the meeting, everyone agreed that they would be unable to go any further until certain preparations had been taken. Mrs. Foster felt just enough hope to start by creating a tiger suit for Nick; that was discussed in some detail. In view of Mrs. Foster’s “combat fatigue,” Mr. Foster agreed to undertake coaching Nick to roar and growl like a tiger. Just as the family was leaving, something that turned out to be serendipitous and extraordinary occurred. Mrs. and Mr. Foster recommended to the therapists a book entitled The Tiger Who Came to Tea (Kerr, 1968).

 The Second Meeting

The second meeting began with Nick demonstrating his strength of purpose by “tiger growling.” Phyllis Brock (the interviewing therapist) sought refuge behind a chair. Nick was surprised and shocked when the one-way screen began to vibrate. Phyllis explained, “David is behind the screen shaking with fear.” When order was restored, the interviewer recovered her composure and inspected the “tigerishness” of his tiger outfit and “the ferociousness” of the screen-printed tiger on his t-shirt.

Another surprise was in order for Nick that day. Phyllis produced her own copy of The Tiger Who Came to Tea and invited Nick to sit by her while she told him a story. He readily agreed, saying that he knew the story only too well.

Phyllis encouraged Nick to relax and close his eyes: “When you close your eyes I wonder if you can see pictures on a TV set in your mind?” Nick nodded as she went on. “Is it a black and white TV or a color TV? Is it a big TV or a little TV?” Nick reported that he could see a “big color TV set” in his mind and started visualizing the well-known tiger story on its screen as Phyllis read.

The Tiger Who Came to Tea tells the story of an outrageous tiger who invites himself into the home of a young boy and his younger sister when their parents are absent. He has a prodigious appetite and eats absolutely everything in the house. There are many illustrations of the tiger devouring cakes, tins of Tiger Food, pots of tea, and even water directly from the faucet. His appetite seems quite insatiable. He departs only after he has eaten them out of house and home. When the parents return to their foodless home, their children tell them of the rapacious appetite of their unexpected visitor. The parents seem to take all this in their stride but that night the family has to eat out. The next day, they restock at the supermarket in anticipation of the tiger’s next visit. The book ends: “The tiger never came again!”

This story was read by Phyllis almost word for word. Except that, of course, there were some calculated changes. Every time the tiger appeared in the story, alterations were made to put a boy in a tiger suit in place of the tiger, e.g., the boy with blue eyes and blond hair dressed in a tiger suit did such and such or the boy who growls like a tiger did such and such.

Also, Nick’s sister Olivia was substituted for the sister in the story. Other changes were made that associated Nick with the ravenous tiger. Before the conclusion of the story, Phyllis hesitated. Nick exclaimed: “And the tiger never came again!” Phyllis took Nick’s hand and gave it a light squeeze. She suggested that he return to his mental TV watching. After a moment she said, “In my story, the tiger comes every other day!”

Nick and Olivia were then asked to wait in another room while the adults talked together. Mr. and Mrs. Foster were delighted and unable to conceal their grinning. They joined the therapists in making conspiratorial arrangements for the tiger to come to tea (dinner) every other night. On the non-tiger days, Nick was to eat for himself; on the tiger days the Fosters were to play a cassette recording of Phyllis’s new version of The Tiger Who Came to Tea while Nick was being outfitted as his tiger. Afterward Nick was to be escorted out the back door and around to the front door while Olivia ran to answer the doorbell. He was to announce himself as a tiger by the requisite growling. Then the tiger would be offered a meal of the food similar to the one illustrated in the book. If they had any difficulties with this, a tiger food lunch box would serve as a replacement.

 Three Weeks Later

Three weeks later the Fosters returned to the center. By then Nick’s coloring had changed so that he looked normal for a boy in summer time. The family reported that “he was just eating quite happily even on the nights between the tiger visits.” Everyone volunteered entries as they catalogued the wide range of meat, fruit, vegetables, and sweets he now was regularly consuming. He was even demanding seconds and had to be reproached for eating off his sister’s plate!

David and Phyllis wondered if his tiger was eating so much that he might become overweight. Nick indicated that this was an unlikely prospect. His activity level was incomparable to the first meeting. He rushed around the room, exploring the toy boxes, using the chalk board, and exciting Olivia with his enthusiasm. The Fosters were somewhat baffled by what they described as “his boisterousness,” although they assured David and Phyllis that this was a concern for which they would enjoy finding a solution. They stated that they were increasing the interval between tiger visits and thought they would soon discontinue them.

Six Months Later

Six months later, when David and Phyllis had a chance to gather follow-up information from the Fosters, Nick’s feeding problem seemed quite remote. But the tiger had returned five more times in the interval, which added up to ten times in total. Nick was no longer going to the doctor with minor illnesses, his hair had “life in it” compared to its being “crisp and dry” before and he was now fully engaged in the play activities of his age mates.

The following is an excerpt from the six-month follow-up interview. The interview picks up with Mrs. Foster recalling a visit to Nick’s pediatrician several months before they first met with David and Phyllis.

“The pediatrician wasn’t all that worried about him,” Mrs. Foster began. “But were you?” asked David. “Well, we just felt it was kind of a psychosomatic thing,” Mrs. Foster explained, “like there wasn’t anything physically or organically wrong with him that was causing him not to be able to eat.”

“Well, it was a minimally satisfactory diet, but I guess parents want more for their kids,” David mused. “There’s more to life than jam sandwiches–there’s carrots, potatoes, and lemon meringue pies. Did you feel that he was being deprived of what was his due in terms of pleasure?” “No,” interjected Mr. Foster, clarifying further, “I just thought that he had restricted himself so much that he was in a tight little corner with the energy and things. I could see that he was restricting himself in that way.”

David paused for a moment and then asked, “What is your understanding of how this situation turned around so quickly? Any ways of thinking about it that might be helpful to us?”

“Well, you sort of helped us really realize . . . ” Mr. Foster started and then stopped to gather his thoughts. “You sowed the seed and gave us some ideas on a way of going about it, and then we were able to carry it out.”

“Have you given yourself credit for it?” David wondered. “I worry that parents don’t give themselves enough credit. Do you feel that you did it or we did it?”

“You gave us the ideas,” replied Mrs. Foster. “We carried them out, but we needed the contact with you to be able to see and adopt a different approach to it.” David shared another family’s outlook: “Some other people said, ‘We got a different angle on the problem.'” “Yes, yes, yes!” Mrs. Foster agreed enthusiastically. Mr. Foster concurred, “Oh yes, it was just that different approach and, as we said earlier on, you get so bound up in the thing yourselves.”

Next David turned to Nick: “I remember that you listened to a story on a cassette tape–right? And what would happen in the story? Do you remember? What did the tiger do that listened to this story?” Nick responded, “Well, he would come down the pathway and come up to the house and then he’d knock at the door.”

“Can you put a sample of his growling on this tape?” David requested. When Nick grinned “yes,” David quipped, “Shall I stand back?” Nick laughed and let loose a mighty growl. “Wow!” exclaimed David.

“And then did Olivia open the door?”

Nick nodded.

“Then what would happen when this tiger came into the house?”

“He would go and sit at the table with my apron on.”

Just then Olivia interjected, “And he would eat all that food!” “All the food,” confirmed Nick.

“He would eat all the food?” echoed David, astonished.

“Yes, and he would be the last one eating at the end because I always stopped and had two or three minutes rest.”

“Why? Did you need a rest because you were so tired from all the eating you were doing?”

“Yes, and after dinner I had ice cream and I used to gobble that up and I always finished it.”

“Do you think this tiger got a little bit bigger and stronger with all the food it was eating?”

“Yes,” said Nick.

“And do you think this tiger that was getting bigger and stronger started having more fun? Making more noise and playing more?” David continued, building on his theme. “Yes,” repeated a smiling Nick.

“That’s a pretty good tiger. Do you think this tiger is a good friend of yours?” David inquired, and when Nick nodded he asked, “What do you want to tell other boys and girls about being a tiger? Anything you want to say?”

Nick documented his comments on the tape: “Well, you start by going to Leslie Centre and they tell you a story.”

“What’s the story like? ” asked David. Nick said into the microphone: “The tiger who came to tea and goes and eats everything and thinks he likes everything on his plate.”

“You go to Leslie Centre and they tell you a story and what happens then?” David summarized. Nick continued:”Then they tell you to make a tiger outfit and then you do your roar like this.” And with that Nick let out a mighty roar. Then he paused and added thoughtfully, “Sometimes when I see it though I think, ‘Oh, I hope I’m not going to be the tiger again ’cause I feel grown-up.'”

David had to wonder out loud when he heard Nick’s comment: “Do you think that you don’t need the tiger anymore? You’ve grown past it?”

Nick nodded, smiling broadly.

“Do you think some boys and girls might be helped by the tiger?” David speculated.

“Yep!” said Nick.

Summary

Over the past ten years, David Epston and Michael White have used the bypass operation with a number of children between the ages of four and seven. These are children who have presented with intractable feeding and appetite problems. This approach has generally followed the guidelines presented here (it has been modified according to the circumstances of each situation), and to date it has been effective in the amelioration of the feeding problems of all of the children referred with such complaints.

Michael and David warn against shortcuts in this work. Such shortcuts are usually the outcome of conceiving of the bypass approach as simply a technique. It is essential that parents be adequately prepared prior to embarking upon this “operation”. This preparation should include interventions to undermine parental self-accusations. Without such relief, the chance of success will be severely diminished. They stress the importance of the groundwork that must be laid in preparing for the this approach; this groundwork, informed by the overall orientation and the politics of the work, is a necessity.

David and Michael believe that they have by no means exhausted the possible applications of “bypassing” as a metaphor in working with a range of children’s problems, especially those where the child is caught up in a mind-body impasse. They also want to emphasize that care must be taken to discern those children who are “failing to thrive” through neglect, unbelonging, or abuse, from those children and families with whom they would typically employ the bypass approach.