_ :2 E :2. ,_ ., MSU RETURNING MATERIALS: P1ace in book drop to LIBRARIES remove this checkout from -:—. your record. FINES will be charged if book is returned after the date _, stamped below. .rxgz ..-- I?” J' rm." Lghib:’,..‘ MICHIGAN STATE UNIVERSIT ‘1 School of Social Work HST WSING, MICHIGAN FAMILY DIAGNOSIS, TREATMENT, AND RELEVANT CONCEPTS: AN EXPLORATORY STUDY presented by William K. Bailey MICHIGAN STATE UNIVERSITY East Lansing, Michigan Dr. Lucille K. Barber November 18, 1963 Professor SW ROOH Mutant 'smsm ‘ ‘ uh VoM [“308 J0 I°°W°S _--.E.nn9('l\ HQQ'QH l—nn-A-‘g— u...“ "w w” W ‘ " 11 3-4.5 \uriv ‘ .u'} ‘~._‘ '._._T b ‘:‘\..C 3-." I a: 2*: .- v ~.‘ daft.- v Mg. -«w “M3" " TABLE OF CONTENTS Chapter Page INTRODUCTION 0 o o o o o o o o o o o o o o o o o o o o o o o o o o 1 I CONCEPTS RELEVANT TO FAMILY DIAGNOSIS AND TREATMENT. o o o o o o o 9 Family StPUCtureo o o o o o o o o o o o o o o o o o o o o o o o 9 family of procreation and family of orientation family sub-systems field of forces Family Inter-Group Interaction . . . . . . . . . . . . . . . . 13 the family as a group family homeostasis-~balancing and opposing forces alignments and splits complementarity communication feedback and calibration double-bind Family Extra-Group Interaction: Adaptation to Society. . . . . 29 adaptation social role culture conflict Family Management of Crisis . . . . . . . . . . . . . . . . . . 33 crisis ego growth II FAMILY DIAGNOSIS . . . . . . . . . . . . . . . . . . . . . . . . . 38 Multiple Client Interview Methods . . . . . . . . . . . . . . . 39 The Subjective Experience of the Family Interviewer . . . . . . 43 Objective Methods of Interaction Analysis . . . . . . . . . . . 44 Chapter Page III FAMILY TREATMENT C C O O O O O O O O O O O O O O O O O O O O O O O 50 The Family Therapist. o o o o o o o o o o o o o o o o o o o o o 50 Criteria for the Use of the Family Interview. . . . . . . . . . su The General Goal and Focus of Family Treatment. . . . . . . . . 56 CONCLUSIONS. 0 O O O O O O O O O O O O O O O O O O O O O O O O O O 59 INTRODUCTION Purpose and Method of Study This is an exploratory—formulative study of family diagnosis, family treatment, and concepts relevant to both. The purpose of this study is J I threefold: First, the investigator wanted to increase his familiarity with K the stated subject area of the research topic. Second, a high priority is / placed upon the clarification of concepts relevant to family diagnosis and treatment. Finally, the writer desired to formulate a precedence among areas seeming to warrant further research. The method of study is that of reading from the existing body of literature written about family diagnosis and treatment. However, the writer did not Inuit himself entirely to this particular body of literature since it was deemed that interesting insights might also be obtained from different research or conceptual contexts. Bacgground of the Problem Increasing attention is being given to the importance of family experiences as a source for individual intra and interpersonal conflict. It is further generally recognized that in order to discover the basis for an individual's present role performance or behavior that it is necessary to go back to the individual's experiences in primary group living.1 Furthermore, a lack of consideration of the family in diagnosis and treatment of the "sick" individual and subsequent failures in therapy have been remarked upon.2 There have been several influential factors which have influenced the importance presently placed upon the development of family-oriented assess- ment and treatment.3 ' First, psychology, sociology, and anthropology have been increasingly influencing the interpretation placed upon data as the result of new insights into behavior. Second, the child guidance movement initiated by the Juvenile Courts expanded the interest of professionals in the area of treatment and research. Also, new data about the family became more accessible. Third, the psychoanalytic movement provided new insights into be- havior and loosened the ties between c1assica1.medicine and psychiatry. Freud's position regarding intra-personal constructs led to an examination lNathan Ackerman, "Interpersonal Disturbances in the Family," Psychiatry, 17, No. u, 195“. For further examples see also: E. J. Cleveland, and N. D. Longaker, ”Neurotic Patterns in the Family," in A. H. Leighton, et. al. (Eds.), Ex lorations in Social Ps chiatr , Basic Books, New York, 1957; Theodore Lidz, et. a1., "The IifrafamiIiaI Environment of SchizoPhrenic Patients: II. Marital Schism and Marital Skew,” The American Journal of P3 chiatr , 11” Baltimore, 1957-58; J. E. McKeown,-'The Behavior of ParEEts of Schizophrenic, Neurotic, and Normal Children," American Journal of Sociology, 56, 1950; Suzanne Reichard, and C. Tillmanz'VPafferns of PaFEnT:CEIIH—Relationships in Schizophrenia,” Psychiatry, 13, 1950; H. B. Richardson, Patients Have Families Commonwealth Fund, Harvard, Cambridge, Mass., 1945. 2Nathan Ackerman, and P. B. Neubauer, ”Failures in the Psychotherapy of Children," in P. H. Koch, (Bd.) Failures in Psychiatric Treatment, Grune, New York, 19n8. Also see: Nathan AcFerman, 'Thterpersonal DisturEEnces in the Family: Some Unsolved Problems in Psychotherapy," Psychiatry, Vol. 19, 195%. 3The following discussion of these factors is based primarily upon the article written by Don D. Jackson and Virginia Satir, "A Review of Psychiatric Developments in Family Diagnosis and Family Therapy,” edited by Nathan Ackerman, et. a1., Exploring the Base for Family Therapy, New York, FSAA, 1961. of previously held positions. However, as time passed child analysts began to discover that there influence with the child was far outweighed by the influence of the family. Also, there developed an increasing dissatisfaction with the large costs compared with the results of this method. Another difficulty which is attributed to the psychoanalytic influence is that since most family therapists are psychoanalytically trained, there has been the result of confusion in the attempt to develop a language for family diagnosis and therapy. Fourth, the awareness of the existence of health, and the concept of adaptation has led to a focusing upon "why" rather than just upon fixed pathological symptoms. This is important from a preventive standpoint, as well as from the treatment side. Fifth, studies of schizophrenia have continually pointed out the importance of the patient's family for treatment of a patient and for prognosis. Finally, the field of social psychology and its study of small groups, and the field of communication and information theory are providing promising areas for exploration in family interaction. It is further pointed out in the above article that social workers have been more successful than analysts in interviewing parents since the analyst is tradition bound. This possibly implies that the social work profession is more reactive to change which is in this case a positive attribute. However, the writer would like to suggest that the answer to the success of social workers rests in the underlying objectives of the profession. Gordon Hamilton outlines two major objectives of social work as being: (1) the development of economic and physical well-being, or a health and decency standard of living; and, (2) providing opportunities for social growth through satisfying relationships and experiences. Furthermore: All professions would stake out an interest in these objectives but there is little doubt that social work occupies a peculiarly inclusive position with regard to both, since the factors in economic and cultural security and individual behavior are interwoven. Moreover: It is this integration which consistently has shaped social work and given it its distinguishable if not wholly distinctive pattern; it is this which gives it its complexities, its frustrations, its fascinations, and its challenge. Thus, the profession of social work functions comprehensively in helping pe0ple with problems. The social worker considers social factors as well as individual dynamics, and will use environmental resources in resolving or handling conflicts which the client is facing. Treatment is primarily supplied through the casework method, and the most effective tool of the social worker is the relationship with the client.6 Regarding assessment or diagnosis, Werner Boehm7 specifies the social workers concern, as differing from other professions, as being that of assessing the impact of certain social stresses upon the patient's psychic equilibrium and to help him to adapt to these ”Gordon Hamilton, Theory and Practice of Social Casework, (2nd ed.) New York, Columbia University Press, 195i, p. If: 51131.21. 6 Besides Gordon Hamilton, the writer also referred to the following sources: A. E. Fink, et. al, The Field of Social Work, New York, Holt, 1955; H. H. Aptekar, The amics of CaseEEFk and CEEhseIin , Houghton Mifflin Company, 1955; and, 'H—eTen gerIi-a'nT-Social Case—fork: A Problem-Solving Process, University of Chicago Press, 1957. """""" ‘— 7 Werner W. Boehm, "The Social Worker as a Psychotherapist: Functions and Educational Preparation, The Trainin of Ps chothera ists, N. P. Dellis and H. K. Stone (Eds.) (Louisiana State finiversity PFess, I960) pp. 57-58. pressures and social situations. With the above background, it is quickly comprehensible why the pro- fession of social work is vitally interested in social factors which shape, maintain, and sometimes with professional intervention, aid in remolding personality. At the practitioner level the family's role in transmission of behavior has long been noted. This has also been referred to above. The role of the family has even been carried further by noted writers on the family. Gardner Murphy8 states that there is a reciprocal relationship between the family and the world as a whole. He views the family as a barometer of what is going on in the world. Furthermore, the family is perceived as being sensitive to trends. For example, children in their development reflect changes in child rearing practices of parents. Miller and Swanson demon- strated in their study of the American parent that there is a trend towards more character disorders, persons who have difficulty in controlling them- selves, and problems of sexual identity. 0n the other hand, there is an expected decrease in disorders involving distortions of perception.9 In short, social forces outside the family may influence family socialization patterns which in turn influence individual growth and develop- ment. At the center of the stage is usually the family which is the point of integration of social variables and individual dynamics. This is a complex process which the following paper will only deal with at an explora- tory level. In the profession of social work today there is some disagreement as to what emphasis and theory is most relevant in treatment of maladjusted 8Gardner Murphy, "New Knowledge About Family Dynamics," Social Casework, July 1959. 9Daniel R. Miller and Guy E. Swanson, The Changing American Parent: A Study in the Detroit Area, (New York: Wiley, 1958) pp. 206-212. behavior.10 The general consensus of opinion, however, tends to indicate that there is a need for integration of socio-cultural factors and psychological pro- cesses. Particularly relevant are the comments of Frances Scherz who points out that such integration, in practice, may be facilitated by focusing on family interaction, collective ego capacity, and cultural material. By including family interaction, our diagnostic base is broadened. A focus upon collective ego capacity increases the scope of casework treatment. In embodying cultural material the worker includes a check on his own culturally base attitudes.ll To conclude, the challenge presently confronting professionals in- volved in diagnosis and treatment of families is the meaningful integration of social science and psychodynamic concepts.12 .As Carol Meyer states, ”Our heretofore restricted view of individual dynamics should be widened to loIllustrative of this disagreement on the one hand is Selma Fraiberg who maintains how psychoanalytic theory provides a precise diagnosis, makes behavior meaningful, and prescribes corrective measures in "Psychoanalysis and the Education of Caseworkers," Ego-Oriented Casework: Problems and Perspectives, H. J. Parad and R. R.-Niller (Eds.) (New York: Family-SErvice AssoCIation of America, 1963) pp. 236-258. On the other hand, Satir and Jackson state their view that they see most contributions as coming from the social sciences since psychoanalysis is limited by a nomadic framework, and the terminology of psychoanalytic theory is not applicable to family work. This is pointed out by Don Jackson, and Virginia Satir in, "A Review of Psychiatric Developments in Family Diagnosis and Family Therapy,” Exploring the Base of Famil Therapy, N. W. Ackerman, et. al. (Eds.) (New York, FSAA, T961) pp._§9-SI. llFrances H. Scherz, "Family Interaction: Some Problems and Implications for Casework," E o-Oriented Casework: Problems and Perspectives, H. J. Parad and R. R. Miller (Eas.) (New Tort: Famin Service Association of America, 1963) pp. 129-1un. Carol N. Meyer, "Quest for a Broader Base for Family Diagnosis,” Social Casework, (July 1959) pp. 370-376. include what we might call 'individual-interpersonal-intersocial-and cultural dynamics.”l3 It is further pointed out that such a synthesis should not only take place in theory but also in practice.lu Limitations of Study This study is limited primarily to a discussion of interpersonal phenomena influencing family group behavior. Thus, the focus is upon inter- action between individuals. Of most concern to the writer are those concepts which seem important from the standpoint of understanding the interpersonal competency or inability of the family group and the members therein. Besides limiting the area of study, the above focus is based upon several underlying assumptions. First, an individual does not exist in isolation, nor can he be viewed as such. Second, a person's emotional- social responses and skills are originally experienced in a primary group, usually family, during the critical early years of personality formation in which interpersonal skills are learned. Third, the behavior of one family member has some influence on the rest of the group members. Plan of Report In Chapter I, the writer discusses concepts which are felt to be relevant to family diagnosis and treatment. There are four major divisions in this chapter under which the concepts are discussed. These are: family structure; family inter-group interaction; family extra-group interaction: adaptation to society; and, family management of crisis. Chapter II explores the methods of assessment used in family diagnosis, and suggests in the section on ”Objective Methods of Interaction Analysis" the use which could be made of 13Celia Brody Mitchell, ”Family Interviewing in Family Diagnosis,” Social Casework, (July 1959) pp. 381-38u. lqu. Cite. P0 370. sociometric techniques in obtaining important data. In Chapter III, Family Treatment, the writer discusses the family therapist, criteria for the use of the family interview, and the general goal and focus of family treatment. Finally, the conclusions of the study are made in Chapter IV. These are primarily in terms of formulating priorities which seem to warrant further research. Chapter I CONCEPTS RELEVANT TO FAMILY DIAGNOSIS AND TREATMENT The following concepts are by purpose family oriented. However, within the confines of the study, the central position which the family holds theoretically for integrating both individual and social determinants of behavior is apparent. As Nathan Ackerman suggests: Personality, family, social structure and cultural patterns are not regarded as separate independent entities, but as interrelated and interacting parts of a unified whole which change and shift over time, each part in dynamic equilibrium with each other. The psychosocial pattern of a given family is determined by the dynamic interplay between intra- and extrafamilial processes. Tension and conflict within the family affect the external adaptation of family to community; similarly, stress in the relations of family and individual members with the community finds an echo in the internal psychosocial balance of the family.15 In this chapter, I have outlined four divisions under which to group the various concepts. First, family structure is discussed. Second, family inter-group interaction is broken down into what are felt to be meaningful parts. Third, family extra-group interaction or the family's adaptation to society is examined through a discussion of pertinent concepts. Finally, concepts relevant to a discussion of family management of crisis are discussed. Family Structure In practice, the structure of a family group constitutes a starting point in the initial phase of exploration of a group since it offers a natural frame- work from which to begin. Several concepts are relevant in a discussion of structure: family of procreation and family of orientation; family sub-systems; 15Nathan Ackerman and Marjorie Behrens, "A Study in Family Dianosis," American Journal 2£_Orthopsychiatry, 26, 1956, p. 68. -9- 10 and, field of forces. Family of Procreation and Family of Orientation: Carol Meyer defines the family of procreation as ”the biological and reproductive unit of parents and child."16 In distinguishing the family of procreation from the family of orientation, we might use Otto Pollak's definition of the latter as “the sum total of persons who form continuous members of the household, and because of this long-term association, exert an influence upon the development of the child who grows up within their group."17 His emphasis is upon a plurality of persons and their impact upon the development of the individual. These concepts provide us with a framework from which we can view the total number of relationships within a family group over a period of time. We not only view the unit of orientation, but also the procreation branch units of the present parents when they were children. After obtaining the "Gestalt,” we can then begin to obtain a clearer picture of the ”parts” and how they fit into the total picture. The "parts" of the family of orientation or procreation have been conceptualized in literature as "sub-systems.” A concept which is helpful in providing a dynamic quality to our picture is that of perceiving a ”field of forces.” Familnyub-systems: Pollak and Brieland outline three sub-systems. These are the marital relationship, parent-child relationship, and the sibling relationship.18 16Carol H. Meyer, "Quest for a Broader Base for Family Diagnosis,” Social Casework, (July 1959) p. 37M. l7Otto Pollak, Inte rating Sociological and Psychoanalytic Concepts, (New York: Russell Sage Foundation, I955), pp. 7-8. 18Otto Pollak and Donald Brieland, I'The Midwest Seminar on Family Diagnosis," Social Casework, (July, 1961). o '7 . . . . -— . - . (- w r O . m l e f' V-.,-.._-» .-. . e ' 1 b ' . v C 7 . 0 ~ ,- "-3 11 In addition to these, the writer would also suggest a fourth sub-system of parent-children. This would differ from parent-child, in that, we would see not only a one to one or two to one relationship but also a parent to children and dual parent to what-ever—number children system. For example, we might explore the attitude of the children towards their parents, and also the parents as a twosome and singularly to the children within the family. The importance of the concept of sub-systems, as any other concept, is to broaden and sharpen our perceptions. For example, suppose in a parent- children sub-system of mother and children we noticed an alienation between the two. In our exploration, we note that the mother has an attitude that children are nuisances and that she transmits this in her daily interaction with them. We have made observation which through follow-up exploration and treatment could lead to a different, and h0pefully, improved relation- ship between the mother (parent)-children sub-system. The next concept provides a dynamic quality to our picture of structure which may already have been hinted at in the previous paragraph. This is the concept of field of forces. Field of Forces: Jules Henry and Samuel Warson approach the subject of family structure and psychic development by extending Kurt Lewin's concept of field of forces. They offer three basic propositions which are relevant to our viewing family structure as dynamic rather than as a static entity. They are: 1. Whatever mechanisms turn out to be dynamic in personality must be conceived of as operating in a field of forces . . . for example, the oedipus complex must be concEIvea as functioning in a total situation . . . 2. The family may be conceived of as a field of forces. It is made up of a complex of interactional systems composed of the individuals in the family. Each one of these systems 12 may, and generally does, have a bearing on the development of personality. The larger the family the larger the number of interactional systems . . . 3. Social structures are relativelygpermanent systems of inter- action or shared activity . . . The importance of these propositions and the earlier work of Lewin for the present discussion is the emphasis placed upon systems of interaction and the influence that these have on behavior developnent. Interaction is particularly important in the American family since emotional relationships between parents and children are very intense in our society. This is in part probably a structural factor since our families are nuclear. Nuclear families can adapt more readily to a modern society in which, for example, nobility is important. However, there is not the dilutional quality of relationships which exist in societies with extended families. This discussion does not imply that families are isolated groups in society. Meyer discusses the concept of an ”extended field of influence” in which she conceives of environment as being a dynamic factor to be considered more fully in treatment. She Specifies the importance of con- sidering a sociodynamic approach to family diagnosis that would enhance the psychodynamic approach currently in use.20 However, despite the fact that we need to assess the environmental factors impinging upon family members, it is important to be aware of the fact that in our society family structures are nuclear and that relationships are much more intense than in extended families in other cultures. 19Jules Henry and Samuel Warson, "Family Structure and Psychic Develop- ment,” American Journal sf Orthopsychiatry, 21, 1951, pp. 59-60. 2OCarol M. Meyer, "Quest for a Broader Base for Family Diagnosis," Social Casework, (July 1959), p. 37!. 13 In short, the writer places a priority upon viewing the family as a field of forces in which there are complex interactional systems composed of individuals in that family. Although, we are aware of the ”extended field of influence” there is not the same importance either theoretically or practically speaking, if we are dealing with behavior disturbances (interpersonal incompetence) per se. Family Inter-Group Interaction Under this division, concepts relevant to the analysis of the inner processes of the family are described. These are: the family as a group; family homeostasis--balancing and opposing forces; alignments and splits; complementarity; and, communication. The discussion of communication is handled in terms of the more specific concepts of feedback and calibration, and double-bind. The Family as a Group: The dichotomy which exists in social casework theory and practice between the individual and social approach has already been mentioned earlier in this project. Paradoxically, this exists despite the fact that the profession of social work has consistently been aware of the interplay of social and psychodynamic factors in personality adjust- ment as well as maladjustment. Sanford Sherman suggests that the concept of the family is the key to the psychosocial puzzle. Expanding knowledge in ego psychology and personality development has emphasized the significance of the family. This has led to greater attention being placed upon the ”client in the group” and dynamic interaction than "the client and the group."21 Thus, we are becoming more 21Sanford N. Sherman, ”The Concept of the Family in Casework Theory," Exploring the Base for Family Therapy, ed. by N. W. Ackerman, et. a1, FSAA, New Yor , 1961. 1M aware of interpersonal competency or inability. By concentrating upon the family as a group,new perceptions are being obtained by professionals which provide insights of diagnostic value into member behavior as well as an important medium for treatment. There is a growing awareness that the family is a group that is in itself a reality that has to be seen and understood as such. Such a realization makes it possible to utilize the insights, methods, and theories of small group theorists. Grace Longwell Coyle in discussing small group theory describes the family as a group which she defines as a ”system"--a set of interacting relationships which has a life of its own, a relation to the larger social and physical environment, a differentiation within its interacting parts, and a constant interaction with individuals as personalities.22 V She further specifies concepts which she feels are generic to under- standing group processes. These are: the process of group formation or establishment of group identity; interpersonal relations or interaction; group control and the exercise of authority; group thinking as a basis for action as a group; emotional aspects of group behavior; and, the value system or group culture.23 Although the above concepts will not each be handled separately at this time, the point has been emphasized that there is a growing awareness of the concept of the family as a group. This is the key concept since, as was pointed out above, it is the initial insight which provides a new path for building upon an already existing body of theory and findings of of the small group theorists. Of importance to the social work practitioner 22Grace Longwell Coyle, "Concepts Relevant to Helping the Family as a Group,” Social Casework, (July, 1962). 23Ibid. 15 is that new concepts are evolving which should improve present observations and treatment methods. Family Homeostasis--Ba1ancingand Opposing Forces: The concept of family homeostasis is actually borrowed from the physiological sciences. It is one, however, that helps clarify complex processes of interactions in the family. Such concepts as intrafamilial alignments and splits, and complementation can really be viewed as processes in family homeostasis. Thus, we might perceive family homeostasis as a primary concept and the above two as being subsidiary. C. F. Midelfort, who has worked extensively with families, views the family as having balancing and opposing psychopathologies. In therapy, he conceives of the family as a dynamic unit in which emotional disturbance is seen as reaction and counter-reaction. Furthermore, one demands as much attention as the other. He also maintains that improvement should be theoretically compounded and a developing mental illness should be prevented.2u It would seem, then,that a family maintains homeostasis through dynamic changes in it's interactional field. The challenge to therapists and researchers is the problem of understanding the family as an interactional field and the processes therein.25 The writer is sure that anyone who has worked with families or couples in therapy has noted the phenomena of improvement in the "sick” member and deterioration in an "adjusted” member. Often the improvement in the client 2“C. F. Midelfort, The Family i2 Psychotherapy, (McGraw-Hill, 1957). 25Don D. Jackson points out the importance of the concept of family homeostasis in understanding the family as an interactional field in the article entitled ”The Question of Family Homeostasis," Psychiatric Quarterly Sgpplement, Part I, Vol. XXXI, No. l (1957) pp. 79-90. 16 who is brought for treatment disrupts the balance in the rest of the group. Therapy must then be oriented towards re-establishing the family's homeostasis. The appropriate treatment goal is to restore this family's functioning at a higher level in which all members benefit and are in equilibrium. In order to diagnose precisely what has been disrupted by the improvement of a particular member of the group, we need concepts which will enable us to make more precise observations. The following concepts of alignments and splits, complementarity, and communication (feedback and calibration, and double-bind) provide a beginning to a clarification of family inter-group interaction. Alignments and Splits: Lyman C. Wynne has contributed tremendously to the clarification of the concepts of alignments and splits.26 He suggests that by focusing upon alignments and splits in therapy with a family will aid in clarifying the complexity of that family's interaction. An alignment is defined “as the perception or experience of two or more persons that are joined together in a common endeavor, interest, attitude, or set of values, and that in this sector of their experience they have. positive feelings toward one another."27 A split is defined "as a comparable perception or experience of opposi- tion, difference, or estrangement, with associated negative feelings."28 In viewing alignments and splits, Wynne has formulized the principle of dynamic equilibrium. This is stated as being "a change in any part of a 26Lyman C. Wynne, "The Study of Intrafamilial Alignments and Splits in Exploratory Family Therapy," Exploring the Base for Family Therapy, ed. by N. W. Ackerman, et. al. (New YorE, FSAA,1961). 27 Ibid., p. 96. 28 . Iblde 17 system whose components are interdependent reverberates to produce change in other parts of the system. ”29 The basic proposition underlying the concept of intrafamilial alignments and splits is as follows: New or heightened alignments of two or more persons are regularly associated with some degree of alienation, or splitting off from others within a same social organiza- tion; the converse is also true. Such splitting or alignment develops automatically and often with only subliminal registration of the previous change that induced it.30 ' Furthermore: If an alignment (or split) is consciously perceived, it is possible that the subsequent alientation (or alignment) may be manifest chiefly in the subjective fantasies and associations of the person who is Split off. If the person does not become aware of the change, he is more likely to respond in one of three ways: (1) make active efforts to split or disrupt the alignment to which he is an outsider and sometimes to ally himself with one of the persons of the disrupted alignment; (2) seek a parallel, new alignment with another group member who is also outside the alignment; or (3) withdraw and reduce his integration with that group, either (a) by pursuing interests and alignments outside the group altogether, or (b) by becoming autistic, often in some sort of fantasied alignment that may replicate an earlier or childhood relationship. What is offered by this concept is a more precise way of observing the interaction of group members. For example, the author points out how by shifting focus within the particular family therapy group, sequentially, from alignment to split and back again, the therapist may become more intimately informed or acquainted with the structure and dynamics of the therapy group as a social system. 29 3 31 Ibid, p. 97. 0Ibid., p. 114 Ibid. l8 Wynne also distinguishes surface alignments and splits from deeper more meaningful alignments and splits. These superficial alignments and splits typify the kind of relationships found in families where one or more members develop schizophrenia or are schizophrenic. Surface alignments and splits are respectively named pseudo-mutuality and pseudo-hostility. The former is defined as "a type of surface alignment that blurs and obscures from recognition and conscious experience both underlying splits and divergences, on the one hand, and deeper affection and alignment, on the other hand."32 The latter is defined as "a split or alienation, which may be exceedingly noisy and intense but remains limited to a surface level of experience and interaction."33 The problem presented by pseudo-hostility and pseudo-mutuality is that a system is maintained in which the individuals involved are vulnerable in their relationships which somehow contain frightening wishes and impulses, and the positive aspects of these feelings and urges can make solely dis- torted contributions to the emotional growth and competency in relationships of the individuals involved. In short, the person does not learn the skills necessary to discriminate or differentiate between divergence or intimacy in relationships. Cgmplementarity: Another way of viewing alignments is offered by the concept of complementarity. Ackerman defines complementarity as "specific patterns of family role relations that provide satisfactions, avenues of 32Ibid., p. 108-109. 33Ibid., p. 109. 19 solution of conflict, support for a needed self-image, and buttressing of crucial forms of defenses against anxiety.'3u He views complementarity as either being positive or negative. Positive complementarity fosters emotional growth of the relationships and of the interacting individuals. Negative complementarity in family relationships signifies a buttressing of defenses against anxiety or neutralization of destructive effects of conflict and anxiety, but does not significantly promote positive emotional growth. The concept of complementarity is very similar to the concept of alignment; whereas, negative complementarity is something like pseudo-mutuality. The main difference is that the concept of intrafamilial alignments, as discussed by Wynne, is much more precise than Ackerman's description of complementarity. Also, where Wynne provides a framework for how other members respond to alignments and essentially focuses upon the ”total” family, Ackerman uses complementarity to explain the behavior of marital pairs or triads. In short, it would appear that the concept of alignments and splits is more useful in working with family interaction; whereas, the concept of complementarity might be of more use in working with marital pairs. In regard to this latter point, Carol Meyer has found the concept of complementarity particularly useful in her work with marital pairs. She defines complementarity as "the mutual emotional tie between marital partners."35 She also suggests that an assessment of complementarity can be based upon the auNathan W. Ackerman, The Psychodygamics of Family Life: Diagnosis and Treatment of Family Relationships, New ork, Basic Books, 1958) p. 86. 35Carol H. Meyer, "Quest for a Broader Base for Family Diagnosis,” Social Casework, (July 1959) p. 37H. 20 following information: 1. The nature of the presenting complaints; the partners' perceptions of their problem; their concerns about their marriage, and their conscious wishes about the direction their marriage should take. 2. The nature of marital functioning in the social role activities of sex relations, parenthood, household management, recreation, and employment . . . 3. The nature of the courtship preceding marriage . . .36 After gathering this information, she found that she could sort marital pairs into three categories; mutually supportive complementarity, mutually combative complementarity, and; lack of complementarity. Again we can note marked similarities between the concept of alignment, and of complemen- tarity. However, when we start to move away from pairs into triads, quadrads, and so on, we would probably find the former concept more useful. Communication: One of the principle problems in gaining meaningful information about family interaction is in comprehending patterns of communica- tion in families. Frances Scherz defines conmunication as ”the kinds of interchanges--verbal, behavioral, and attitudinal, both in conscious expressions and in those derived from the unconscious--that are in harmony with the realistic and affective needs of all members of the family."37 This is an excellent definition of the kind of communication we are interested in as caseworkers. The one weakness in the definition, however, is that we are not only interested in harmonious interchanges, but also those that are 36Ibid., pp. 375-376. 37Frances H. Scherz, ”Family Interaction: Some Problems and Implications for Casework," Ego-Oriented Casework: Problems and Perspectives, H. J. Parad and R. R. Miller (edST), INewEYork,—FSAA,'1963)'p. 134. 21 disruptive. Both must be included so that we will have a fairly complete diagnostic picture in order that treatment decisions can be made more accurately. Scherz makes a very important point in his article. This is: ”The good intent to support troubled peOple becomes confused at times with failing to help then face their problems as realistically as they can, or fearing to ask them to undertake difficult tasks in treatment."38 Support, although well intended, can often be misleading to a client and often have an adverse affect in treatment of the client or group. The causes of missused support on the part of the therapist can be numerous, however, only one will be mentioned here. This is that the caseworker's observations may be limited by his theoretical framework or operational concepts. Consequently, the social worker may overlook behavior which would be extremely meaningful diagnostically and useful therapeutically. Communication is a concept that is often taken for granted in literature despite the fact that it is our main means of expression. In practice, we depend almost exclusively on communication--verbal and nonverbal. Very per- ceptive and adept therapists probably use a number of senses extremely well in receiving responses from a client. Sometimes this reception is conscious, but other times probably more at a subliminal level. This subliminal recep- tion is possibly what provides raw data for intuitive feelings about a client. As our understanding of behavior improves so does practice. We not only have intuitive feelings, but also conscious guides which help provide for more consistently applied treatment techniques and diagnostic perceptions. In the area of communication, two important breakthroughs have been made. One is 3°Ibid.. p. 137-138. 22 the conceptualization of the processes of feedback and calibration, and the other is the theorization of the double-bind. 0f the two, the double-bind is probably the most provocative, and the most space will be given to describing this concept. (a) Feedback and Calibration: Gregory Bateson states that individuals, families, and communities maintain stability by the two processes of feed- back and calibration. Calibration is defined as an economical method of solving problems by the substitution of habit for feedback. Feedback, on the other hand, is merely the method of trial and error, for which calibra- tion is a short out process.39 In continuing, Bateson makes the point that there is stability in schizophrenic families. First, they are ”close intercommunicating systems” despite unhappiness and external devisive forces. Second, a patient may show improvement, and other members of the family may push him back or one of them may show psychological disturbance. Third, the family gives the outward appearance of respectability; however, the patient may disrupt this facade. Finally, schizophrenic families present a stability not true in other families. To substantiate this the author explains that descriptive statements of family members remain true longer than in other families. The problem, however, in schizophrenic families according to Bateson is that they are at a very low level of individual habit formation and at the highly superficial level of external appearances. The contribution that Bateson makes in such a statement is that he suggests that family stability may be depicted as having levels of stability. 39Gregory Bateson, ”The Biosocial Integration of Behavior in the Schizo- phrenic Family,” Exploring the Base for Family Therapy, ed. by N. W. Ackerman, et. a1., (New York: FSAA, 1961). 23 The feedback and calibration in these disturbed families is distorted by the communication amongst the members. A concept which has been theorized to explain how a person may develop schizophrenic symptoms in the communication matrix of a particular family is that of the double-bind. In the above discussion, the stage has been set for the discussion of the double-bind concept by the description of the processes of calibration and feedback. These processes provide us with a picture of patterned and predictable behavior in particular families. How this arises may, in part, be suggested by such concepts from communication theory as the double-bind. (b) The Double-Bind: The concept of the double-bind is one that is being used more frequently by professionals interested in family therapy.“0 In the following paragraphs, I shall attempt to clarify what is meant by "double-bind.” To begin with, it might be helpful to state the definition 41 of a double—bind, as it appears in the original paper. The necessary ingredients for a double-bind situation, as we see it, are: 1. Two or more ersons. Of these, we designate one, for purposes of our definition, as the "victim.” We do not assume that the double-bind is inflicted by the mother alone, but that it may be done either by mother alone or by some combination of mother, father, and/or siblings. 2. Repeated experience. We assume that the double-bind is a recurrent theme in the experience of the victim. Our hypothesis does not invoke a single traumatic experience, but such repeated experience that the double-bind structure comes to be an habitual expectation. “OOtto Pollak (seminar leader), Family Diagnosis Seminar--McCormick Fund, June H, 5, 6, 1962 (mimeographed notes). See also: Paul Watzlawick, "K Feview of the Double-Bind Theory," Family Process, Vol. 2, No. 1, (March 1963) pp. 132-153. ulGregory Bateson, Don Jackson, Jay Haley, and John Weakland, "Toward a Theory of Schizophrenia," Behavioral Science, 1, pp. 253-254. 3. fl. 5. 6. 24 Aprimary negative injunction. This may have either of twojfbrms: (ajfufio not do so and so, or I will punish you," or (b) "If you do not do so and so, I will punish you.” Here we select a context of learning based on avoidance of punishment rather than a context of reward seeking. There is perhaps no formal reason for this selection. We assume that the punishment may be either the withdrawal of love or the expression of hate or anger-~or most devastating-~the kind of abandonment that results from the parent's expression of extreme helplessness. (Our concept of punishment is being refined at present. It appears to us to involve perceptual experience in a way that cannot be en- compassed by the notion of "trauma.”) A secondary injunction conflicting with the first at a more abstract level, and like the first enforced T%punishments or signals which threatened survival. is secondary—injunction is more difficult to describe than the primary for two reasons. First, the secondary injunction is commonly communicated to the child by nonverbal means. Posture, gesture, tone of voice, meaningful action, and the implications con- cealed in verbal comment may all be used to convey this more abstract message. Second, the secondary injunction may, therefore include a wide variety of foams; for example, "Do not see this as punishment;' "Do not think of what you must not do;” "Do not question my love of which the primary prohibition is (or is not) an example;' and so on. Other examples become possible when the double-bind is inflicted not by one individual but by two. For example, one parent may negate at a more abstract level the in- junctions of the other. A Ltertiary negative injunction prohibitin the victim from escaping from the field. In a forma§ sense it is perhaps unnecessary to list this injunction as a separate item since the reinforcement at the other two levels involves a threat to survival, and if the double-binds are imposed during infancy, escape is naturally impossible. However, it seems that in some cases the escape from the field is made impossible by certain devices which are not purely negative, e.g., capricious promises of love, and the like. Finally, the complete set of ingredients is no longer necessary when the victim has learned to perceive his universe in double-bind patterns. Almost any part of a double—bind sequence may then be sufficient to pre- cipitate panic or rage. The pattern of conflicting injunctions may even be taken over by hallucinatory 25 voices.‘42 The authors application of the double-bind to the family situation is hypothesized as having the following attributes or characteristics: 1. A child whose mother becomes anxious and withdraws if the child responds to her as a loving mother. That is, the child's very existence has a special meaning to the mother which arouses her anxiety and hostility when she is in danger of intimate contact with the child. 2. A mother to whom feelings of anxiety and hostility toward the child are not acceptable, and whose way of denying them is to express overt loving behavior to persuade the child to respond to her as a loving mother and to withdraw from him if he does not. "Loving behavior” does not necessarily imply "affec- tion;" it can for example, be set in a framework of doing the proper thing, instilling "goodness,” and the like. 3. The absence of anyone in the family, such as a strong and insightful father, who can intervene in the rela- tionship between the mother and the child and support the child in the face of the contradictions involved.“3 In such a situation, the mother expects the child to affirm her love, and deny his feeling about the real meaning of her communication. In supporting the mother's self-deception, the child learns to falsely discriminate his internal communications as well as communications with others. The authors also point out how, the child by not being able to discuss the situation, is prohibited in using the metacommunication level-~"the level we use to correct our perception of communication behavior."”“ In summarizing the family situation, the authors specify that if the child indicates love or affection, he is punished; if he does not indicate 2Gregory Bateson, et. a1., Perceval's Narrative, A Patient's Account of His Psychosis, 1830-1832, (Stanford University Press, 1961). #3 Bateson, et. a1. "Toward a Theory. . .," p. 256. ““Ibid., p. 258. 26 love or affection, he is punished. In either case, escape routes, such as gaining support from others, are cut off. The important fact is that the family relationship is the one which provides the model for all others. In short, the child, it is hypothesized, that later becomes schiZOphrenic is repetitively exposed to double-bind situations in early formative relation- ships. One of the major criticisms of the double-bind is that it is generally recognized that schizophrenics are exposed to such a situation; however, so are many neurotics and normal people. However, it seems that such criticism, in itself, may constitute a kind of validation for the concept. Implicit in such criticism is the inference that the double-bind may be universal since most peeple are at one time or another faced with such a situation. The primary difference between "nomal" and ”abnormal” as pointed out in the authors definition, may be viewed as the repeated experience that the schizophrenic has in relationships with double-binds. What was not made clear in this definition is that there was little indication that there is a mutuality in double-bind situations. The authors designate under their first point that one person is the "victim." It appeared that where we have such a situation, assuming a mutuality or reciproc- ity in relationship, that both persons would be in effect ”victims." Weakland, in a later paper, clarifies this point, i.e., a double-bind is binding on both individuals.“5 In commenting on the therapeutic implications of their hypothesis, the authors make the following notations: 1. Double bind situations are created by and within the psychotherapeutic setting and the hospital milieu. as John Weakland, "The Double-Bind Hypothesis of Schizophrenia and Three- Party Interaction,” in D. D. Jackson (ed.) The Etiology of Schizophrenia, (New York, Basic Books, 1960). 27 From the point of view of this hypothesis we wonder about the effect of medical "benevolence" on the schiZOphrenic patient. Since hospitals exist for the benefit of personnel as well as--as much as-- more than--for the patient's benefit, there will be contradictions at times in sequences where actions are taken "benevolently" for the patient when actually they are intended to keep the staff more comfortable. We would assume that whenever the system is organized for hospital purposes and it is announced to the patient that the actions are for his benefit, then the schizophrenogenic situation is being perpetuated. This kind of de- ception will provoke the patient to respond to it as a double-bind situation, and his response will be "schizophrenic" in the sense that it will be indirect and the patient will be unable to comment on the fact that he feels that he is being deceived. One vignette, fortunately amusing, illustrates such a response. On the ward of a dedicated and ”benevolent" physician in charge there was a sign on the physician's door which said "Doctor's Office.’ Please Knock." The doctor was driven to distraction and finally capitulation by the obedient patient who carefully knocked every time he passed the door. 2. The understanding of the double-bind and its communi- cative aspects may lead to innovations in therapeutic technique. Just what these innovations may be is difficult to say, but on the basis of our investigation we are assuming that double-bind situations occur consistently in psychotherapy. At times these are inadvertent in the sense that the therapist is imposing a double-bind situation similar to that in the patient's history, or the patient is imposing a double-bind situation on the therapist. At other times therapists seem to impose double-binds, either deliberately or intuitively, which force the patient to respond differently than he has in the past.“6 In the article, the authors give an example of how. Frieda Fromm- Reichmann intuitively uses double binds in psychotherapy.* 1+6Bateson, et. a1., "Towards a Theory . . .," p. 263. *The reader may be interested in reading this account in the original article. 28 Recently, the writer had the experience of attending a seminar conducted at the Lansing Child Guidance Clinic in which George Bach was the principal “7 He described from his experience in establishing a group therapy speaker. program in a mental hospital how the group therapist, by recognizing his own feelings and vested interests, was more capable of communicating with the patients with constructive results to these patients. When the therapist was asked a question by a patient, the answer was to be shared honestly with that patient and the group. Essentially, Dr. Bach, from his own theoretical framework, was suggesting from a double-bind standpoint that these group therapists recognize the double-bind that they could be putting the patient in by not recognizing their own motives. In the particular setting that Dr. Bach was describing, the group therapy sessions are monitored by tape and tv. This serves as a later check upon what transpired between therapist and group and amongst the group. In short, honesty and genuineness in relationship was stressed as of utmost importance in therapy sessions. This, from a double-bind viewpoint, would help enable the patient or client to become emancipated from the original double-bind situation. Regardless of the above speculation, the problem still exists for the double-bind theorist of formulating the positive side or picture of the essentially negative double-bind situation. Such a formulation would pro- vide added meaning to therapeutic intervention. “7George Bach is a leading psychotherapist in the Los Angeles area who came to Michigan to conduct a workshop at Eastern Michigan University in Ypsilanti. He is presently having a book published entitled The Intimate Enemies, and is the author of Intensive Group Psychotherapy, (New York, Ronald Pfess, 1954). It is interesting to note that BaCh was a student of Kurt Lewin who is well known as a pioneer in group dynamics, and the experimental study of human relations, Lewin worked on the concept of the approach-avoidance conflict which is very similar to the double-bind situation, and it was interesting to me to note how Bach has apparently used this knowledge, either consciously or subconsciously, in devising his own approach as a therapist. 29 In concluding, the primary value of the concept of the double-bind, as different from other interpersonal approaches such as Sullivan's, is that it focuses more precisely upon properties or attributes of relationships instead of strictly intrapersonal mechanisms. Such concepts further our comprehension of inter-group interaction, and the concommitant results upon individuals therein. Family Extra-Group Interaction: Adaptation to Society Adaptation: O'Kelly and Huckler in their book Introduction to Psycho- pathology summarize the different views of normality and abnormality and in general regard them as inadequate. These are: the over-simplified definition derived from medicine, statistical definition, social relativity, and dichotemization.“8 They approach the subject of normality or abnormality from the standpoint of adaptation. Adaptation is viewed as a generally inclusive concept since "any manifestation of life is to some degree adaptive.“9 The authors under- score this as a significant guiding principle in understanding maladjustment since ”it provides a basis for evaluating any or all kinds of behavior in a way that is objective and free of ethical or moral bias."50 Probably basic to most therapists are the authors' two statements: ". . .every individual does what he does because that is the only possible thing he could do in his particular circumstances."; and, "What we are chiefly interested in are the circumstances that make the person behave in such a way uaLawrence I. O'Kelly and Frederick A. Muckler, Introduction to Psycho- pathology, (Prentice-Hall, 2nd ed., 1959) pp. 16-35. #9 Ibid. ’ p. 30. 50Ibid. 30 that he is called abnormal by his fellows and the factors that lower his adaptive efficiency."51 Importantly, the concept of adaptation has helped lead to the focusing on the ”why” of the particular illness rather than on fixed pathological symptoms. The present discussion will not be focused on answering any "whys" but of necessity will leave this to basic research. From an operational stand- point, however, there are concepts in present use which may be of utility in viewing how a particular family or member from that group is adapting in society. The importance of the concept of adaptation has already been mentioned. In the following discussion, the concepts of social role, social interaction, and culture conflict will be commented on. Social Role: Charles Cooley probably beat Carl Rogers to the "reflection" idea when he used the term "looking—glass self" to describe personality from the viewpoint of social determinants. Cooley implied that a person's con- ception of self comes from the way other individuals or groups react toward him. Furthermore, this reflection makes up his self-image which becomes of central importance in his personality. In short, society helps define the situation for the individual; social images become internalized and people tend to play the role of social expectancy.52 Freud probably refers to the same process when he describes the process of incorporation, and identificatio -- fonmation of ego, and superego. The concept of social role is used as an integrational one by most authors, and is viewed as the abstraction which describes how the total personality functions 511bid., p. 23. 52Charles H. Cooley, Human Nature and the Social Order, (New York, rev. ed., Charles Scribner's Sons, 1922). 31 or adapts in society. Nathan Ackerman, for example, describes "social role" as being synonymous with the Operations of "social self" within the context of a particular life situation. Furthermore, he views "social role" or "social self” as being the integrational aspect of the total personality which is expressed in social actions. Conflict is pictured as arising when social self is not in accord with individual or inner self. From this theoretical base, Ackerman views group psychotherapy as offering a natural approach to the problems of ego function and character adaptation.53 Another writer, Carol Meyer, defines social role ”as the link between the personality and the social environment, the culturally determined unit of individual adaptation, or the coming together of biological drives, ego identity, and the demands of society.”5u Although her definition is not quite as clear as Ackerman's, the basic ideas are the same. She also makes the important point that personality structure and social role exist simultaneously and are mutually dependent. The viewpoint set forth in Meyer's paper is that as social workers we are committed by the nature of our function to look at human behavior more broadly. Social role was suggested as one of the concepts which would help us in making such observations. Culture Conflict: Carol Meyer states that since "casework treatment is related to the conscious goals of clients, we are obliged to have knowledge of the cultural determinants of their behavior.” Furthermore, caseworkers ”are faced continually with value considerations that are directly related to 53Nathan N. Ackerman, Group Dynamics, "'Social Role and Total Personality," American Journal of Orth0psychiatry,’2l, 1951, pp. 1-17. 5». 1 Meyer, ”Quest for a Broader . . .,” p. 373. 'llllll’ll'll 32 cultural determinants."55 She points out that by having an awareness of cultural relativity a worker will be less tempted to try and change a family's way of life, and instead will try to determine what satisfactions are being gained by the people involved in the particular situation. Otto Pollak, however, tends to view the concept of culture conflict ”not so much as an aid in diagnosis and therapy directly but as a conceptual tool in identifying values and attitudes held by the therapist which inter- fered with the application of a truly situational approach in clinical practice."56 The writer's opinion is that both of the above positions are of value in that it is helpful to know facts about the client's culture as well as being aware of our own cultural (personal and professional) values. This is important because we will learn more about how the client views his external world and how we differ. Experience has been, however, that cultural differences tend to disappear in casework treatment when we relate at the feeling level. For this reason, cultural conflicts tend to be of secondary rather than of primary importance. Sometimes though it is necessary to start at the external cultural level and gradually work inward towards the internal feelings that the client may have about his, her, or their backgrounds or actions in the present situation. From the social side, society has rules which determine what is appro- priate and inappropriate behavior. Sometimes individuals and groups come into conflict with these rules and are judged as acting inappropriately. When a family or one of it's members is not adapting to society--it is at the point 551bid., p. 37u. 56Otto Pollak, Integrating Sociological and Psychoanalytic Concepts, pp. 16-17. I'll-I‘ll“ '1 33 of conflict that they come into contact with courts and social agencies. We, as caseworkers, are often faced with the task of aiding that family or member to readjust to the expectations of general society. From this perspective, it is necessary for caseworkers to be aware of the laws and rules in a particular society which govern it's citizens behavior. At points, it will be necessary to interpret expectations of general society to our clients in our work with them. How this is handled will depend upon the setting which the caseworker is in, and upon his skills. In concluding, the caseworker's primary concern is with the client's or clients' feelings which were at the base of his or their actions. However, as an implicit if not explicit representative of general society we will be helping the c1ient(s) to set limits and make adjustments in his (their)behavior. Such concepts as adaptation, social role, and culture conflict offer important guidelines, even if secondarily, in our increasing understanding about families and their members interaction with and adjustments to society. Family Management of Crisis Over a period of time, families tend to establish a pattern of adapta- tion and defensive maneuvers as do individuals. By a particular pattern the members of that family stay in equilibrium, even if tenuous, with one another. The flexibility or rigidity of a family system to change will in part be determined by the secondary gains achieved by the various individuals from the group and in interaction with one another. A family is probably most accessible to change when their pattern of adaptation has been disrupted by some stressful situation or crisis. How a family manages a crisis, and what this means for caseworkers will be discussed in the following paragraphs dealing with the concepts of crisis and ego growth. 34 Crisis: Howard J. Parad in his discussion of the rationale and technique of brief, ego-oriented casework with families in crisis offers the following definition of crisis: . . .a crisis consists of a hazardous circumstance or stress that constitutes a threat for individuals and families whose psychological organization makes the stressful event meaningful in terms of two broad criteria: (1) the stress threatens important life goals such as health, security, or affectional ties, and (2) the threat posed by the stress appears impossible of inmediate solution and overtaxes the immediate resources available to the ego. Parad points out that the ego in relating the organism to the reality principle in response to the stressful stimuli, is faced with the important tasks of perception, mediation, integration, mastery, and control.58 It is held by the author that early casework intervention based upon precisely articulated diagnostic formulations can enable the particular family through the experience of ego mastery of the crisis situation to be strengthened so as to be able to cOpe more effectively with life problems. Three reasons are given in favor of imediate therapeutic contact from a study at the Langley Porter Neuropsychiatric Institute: (1) the actual facts concerning the stress configuration are less likely to be distorted; (2) the more active the conflict, the more amenable it is to treatment; (3) before a new equilibrium has been set, secondary gain gratification is avoided, thereby intensifying the patient's motivation for help. 57Howard J. Parad, "Brief Ego-Oriented Casework with Families in Crisis," Ego-Oriented Casework: Problems and Perspectives, H. J. Parad and R. R. Miller 133.7, (New York, FSAA, 1953) p. 1M6. Sglbid,, p. 1u7. (Also see chapter 3 of this volume.) 59Betty L. Kalis, et. a1., 'Precipitating Stress as a Focus in Psychotherapy," AMA. Archives of General Psychiatry, Vol. V, No. 3 (1961), p. 225. (as appears ifirParad'article). 35 The caseworker, in intervening, is viewed as participant, observer, and agent of change. The casework approach is viewed as being more active and con- fronting, and although some regression is perceived as inevitable, it is discouraged. This is so that transference does not follow the classical casework adaptations from the psychoanalytic model of planned regression in insight therapy. The general goal of this treatment is to achieve an adaptive integra- tion out of a crisis situation. The focus, it seems, is upon ego growth through the management and resolution of crisis. Ego Growth: The concept of ego development is a Freudian one which in the past few years has been given increasing attention by practitioners and theorists. It is a concept which applies essentially to individual personality structure. In Freud's theory the ego is viewed as the central part of the personality which mediates between unconscious impulses and personal plus social standards. As seen in the preceding discussion concerning crisis, we often work with clients at an ego level. This is probably particularly true when our focus in casework is upon interaction at the interpersonal level. John and Elain Cumming in their book Ego and Milieu point out that a number of theories concerning ego formation (including Lewin, Federn, Parson, and Erikson amongst others) are based upon the assumption that "periodic dis- equilibriums between a developing child and his environment are followed by resolution and re-equilibrium at a higher level of ego organization."60 On the other hand, ”failure to resolve any developmental crisis leaves a child inadequately prepared to solve future ones because he has few or poorly 6OJohn Cumming and Elain Cumming, Ego and Milieu, (New York, Atherton Press, 1962) p. us. 36 differentiated sets and perhaps an inadequate level of organization."61 The Cummings are writing primarily from the context of the hospital and milieu therapy; however, the generic concept of ego growth applies not only to that setting but also could be extended to family treatment. For example, we could make useful adaptations from the following quote: . . .ego growth is essentially a series of disequilibriums and subsequent re-equilibriums between the person and the environment. Therefore, by extension, it seems reasonable that growth might be induced by presenting the individual with a series of graded crises under circumstances that maximize his chance of resolving them. In other words, crisis resolution should be a therapeutic tOOl that can he scientificaliy controlled. Thus, if an’individuai has been unable to solve problems because of inadequate biological endowment or extreme environmental stress, he should experience ego growth and re-organization if he is introduced to carefully controlled minor crises in a protected situation. Obviously, we do not have the controls of the hospital situation, nor in many cases would we want them; however, the caseworker does offer individuals and families many of the same qualities. Importantly, the caseworker provides families in crises with support--both psychological as well as environmental help. Crises can often be therapeutically minimized so that a family or individual can overcome a stress and develop greater ego strength for handling future crises. In using the concept of "crises" I again emphasize social and psychological since the two are irrevocably intertwined with one another. This concludes the discussion of concepts relevant to family diagnosis and treatment. There are probably many more which could have been brought into this discussion; however, the project was not devised so as to be exhaustive, or to elaborate upon any single concept in depth. The four divisions of family structure, family inter-group interaction, family extra-group interaction, and 62 Ibid., p. 56. family management of crisis are so designed however that other concepts could be meaningfully added in future studies. 37 Chapter II FAMILY DIAGNOSIS Writers concerned with clarifying what is meant by family diagnosis seem to be in agreement that the individual member must be viewed within the context of the group interaction and behavior. Satir and Jackson, for example, believe that the terms "'family diagnosis' and 'therapy' should be restricted to those systems of study where the therapist's impression of state X in subject A carries probability statements about subject B; if B is in the same nuclear family and at a different level, A's inferences about B change A's probable (behavior, motivation and so on) from X to X1, X2, and so on." They also point out that the focus in individual therapy tends to be on how A feels about B or about himself, without shifting levels.63 Pollak tends to concur with the basic assumption underlying the above statement only from a different theoretical framework. He views family diagnosis as consisting of clinical, genetic, and dynamic assessments of every member of the child's family or orientation, combined with an inter- active and institutional analysis of the family as a whole. By institutional analysis, Pollak is referring to the family as an integrated unit of human activities designated to satisfy basic needs. His interaction analysis appears to be based upon individual dynamics, and reactions upon and toward other family mambers.6n 63Jackson and Satir, ”A Review of Psychiatric Developments . . .,” p. 31. 6“Otto Pollak, Integgating Sociological and Psychoanalytic Concepts. -38- 39 Nathan Ackerman, in approaching the family, states in his book The Psychodyaamics of Family Life that he attempts "to correlate the dynamic psychological processes of individual behavior with family behavior in order to be able to place individual clinical diagnosis and therapy within the broader frame of family diagnosis and therapy."65 Moreover, in another source, he states the following objective of family diagnosis: The task of family diagnosis is to establish the specific dynamic relations between the balance of tendencies to health and illness in a given family type and the parallel tendency of the group to maintain emotional health in its members or induce in them special forms of psychiatric disablement.66 In short, Ackerman is also attempting to view the family interaction and the influence of that interaction upon the various individual members. The above discussion establishes the level of observation of family diagnosis as being primarily interactional. The problem in the remainder of this chapter will be to describe the various methods currently being used in obtaining information from which to make a family assessment or diagnosis. These methods will include first, multiple client contact methods including home visits, and in-office multiple interviews; second, the importance of the subjective impressions or feelings of the caseworker; and finally a brief discussion of the possibility of adapting sociometric techniques for the purpose of family diagnosis from the small group theorists. Multiple Client Interview Methods The use of multiple interviewing will be discussed more fully in the next chapter related to treatment. However, multiple interviews offer 65 Nathan Ackerman, The Psychodynamics of Family Life, pp viii. Nathan Ackerman, "A Dynamic Frame for the Clinical Approach to Family Conflict,” N. Ackerman, F. Beatman, and S. Sherman (eds.) Exploring the Base for Family Therapy, (FSAA, 1961), pp. 59-60. no significant insights and data for assessing a family's mode of adjustment. As discussed here, the writer will briefly outline the kinds of interviews and the observational data that can be obtained. One method of studying family interaction is through home visits. In home visits, interaction can be observed first hand. Despite the fact that the interviewers presence has an effect upon interaction, behavior is still more apparent in the home than in the office. Frances Scherz points out how by observing the family's behavior towards one another in the home can eliminate many distortions in verbal comunication in an office inter- view. The example was provided of a mother who complained in the office of how her son clung to her incessantly, but it was noticed in the home inter- view that she actually reinforced this pattern herself.67 Such insights as these are time saving, and clarifying for diagnosis. Viola Weiss points out another value of the home visit is that the family reveals how they view themselves since the social worker is their guest. (In her terms, "a representative of the outside world.")68 How the social worker is treated in the home, then, may be indicative of how the family views and feels about society or persons from ”out groups.” Another method of studying family interaction is through in-office multiple or joint interviews. The in-office interview offers many of the same advantages as the home visit except the emphasis may be slightly different, in that the client is the caseworkerh”guest" instead of the converse being the case. How the clients come to "feel" in that office may eventually determine to some extent how they continue to view other individuals and groups in society. 67Scherz, ”Family Interaction . . .," p. 139. 8 O O 0 O O 6 Viola W. Weiss, ”Multiple-Client Interv1ew1ng: An A1d 1n D1agnosis," Social Casework, (March 1962) p. 113. #1 With the above background established, the writer would now like to move into a discussion of the kind Of observational data which can be obtained in either home visits or office interviews. From seeing the family as a group, it is possible to more accurately assess the ego strengths Of the various members. As each respond to the pressures and stimulation which come from the others, the caseworker can gain impressions Of the respective family members capacities to tolerate a delay in obtaining satisfactions, and handle frustrations. Moreover, it is possible tO obtain information on how various members interpret the responses of others, and how realistically they tend to evaluate themselves. As an individual is compelled to react quickly, the caseworker can also view emergency defenses or actions which are used by the various individuals such as anger, crying,humor, and so forth. Viola Weiss explains the same thing, only more precisely when she states that the worker can obtain an idea of how family members perform their family roles, directly observe transactional responses (and distortions in client reporting), and observe behavioral responses that reveal preconscious and unconscious data. She characterizes current interviews with a family as obtaining a cross-sectional view Of how the family is presently functioning. She also points out, however, that in order to have a complete diagnostic picture, both a longitudinal assessment as well as an Operational view of the family is needed besides cross-sectional information.69 Celia Mitchell, in the following quote, indicates the complexities which 69Ibid., pp. 111-11u. By longitudinal, Weiss is referring to personal and famiiy history. Regarding Operational, she means those elements which comprise family identity (sense Of stability, continuity, and relation to communities perception thereof). 42 confront the caseworker in family interviews. She states: Postural characteristics, tonal quality, disturbances in communication, the alliances and the scapegoating, the discrepancy between verbalization and behavior not only present diagnostic clues but from the beginning set in motion therapeutic forces. These multiple impressions and stimuli require that the worker, while being aware Of what is going on in each individual, keep his attention focused on the emotional interaction between the family members. 0 In short, the caseworker while Obtaining important diagnostic cues, individually and groupwise, is also participating in therapy with the family. Otto Pollak and Donald Brieland outline six questions which they feel are relevant in a diagnostic study which are worth mentioning here. These are: 1. What is the most burdensome problem and how is it expressed in family interaction? 2. Is the problem affected by a deficit or excess in family membership? 3. Is the problem created by the interaction mutually harmful? u. Does the problem result from external pressures, such as long-term hospitalization or unemployment, or monetary demands that cannot be met by the family income? 5. Is the problem created by the internal pressures of one partner, which would interfere with his capacity for satisfactory relationships regardless Of the characteristics Of the other partner? 6. In view Of the causative factors, how can the caseworker help the members of the family group change?71 The matter of the ”most burdensome problem" or problem of major concern is one that is a recurrent theme in the literature concerned with family diagnosis and treatment. This “problem” facing a family is usually a strong motivational factor for casework treatment since it usually arises out of 70Celia Brody Mitchell, "Family Interviewing in Family Diagnosis," Social Casework, (July 1959) p. 38%. 71Otto Pollak and Donald Brieland, "The Midwest Seminar on Family Diagnosis and Treatment,” Social Casework, (July 1961) p. 321. '43 some stress or crisis. How a family meets crisis is an important diagnostic clue, and has already been discussed in the previous chapter. In concluding this discussion on multiple interviewing for diagnostic purposes, it should be pointed out that what has been emphasized by the various writers could in large part be understood within the conceptual framework set forth in Chapter I. In the next section an elaboration upon the subjective experience Of the caseworker, and its value in family diagnosis will be made. The Subjective Experience Of the Family Interviewer Emily Faucett states that caseworkers have long subscribed to the prOposi- tion that an individual's difficulties lie within his experiences in his family but that caseworkers hesitate to deal directly with the family unit. She further suggests that this may be the result Of a lack Of awareness Of behavior in group relationships, and may have aroused feelings that the worker has long defended against or had under control.72 Both of the above may have validity; however, the writer's Opinion is that the use that is made of a relationship, whether with a group or individual, will depend upon the skill, training, and self-awareness Of the social worker. Moreover, the most effective tool Of the social worker is the relationship with the c1ient(s). Furthermore, this relationship is a sensitively perceptive yet Objective relationship which is developed to recognize, understand, and sustain or modify the client's or family's feelings and attitudes involved in his, her, or their methods Of cOping with life situations. Lyman Wynne, in his discussion Of diagnostic clues as tO alignments and splits in families, states that an important source ”is the subjective experience 72Emily C. Faucett, ”Multiple-Client Interviewing: A Means Of Assessing Family Processes,” Social Casework, (March 1962) pp. 11n-120. an of the therapists, their shifting feelings and fantasies in relation to the other members Of the family therapy group."73 This seems to be a very important point that is worth emphasizing. A caseworker needs to identify his own feelings about his clients, and in fact, should set aside time to reflect (introspect) upon the particular client-worker relationship. In this way the worker may gain interesting insights about the family group, and also identify countertransferences on his part toward various members Of the group. In specifying countertransference reactions, this may involve looking at members Of the group and self reactions, impressions, and resemblances that remind the caseworker of persons he has known in his own past family relationships or experiences with other persons. In this fashion, the worker becomes aware of feelings which enable him to sort out possible distortions, and handle countertransference. In terms Of insights about the individuals in the family therapy group, the caseworker may be reacting to them as other persons in the environment have or do, or as the various family members react to one or more Of its own members. This will in turn help the worker to Obtain a fuller understanding Of the individuals in the family group. Objective Methods of Interaction Analysis As has been implied in the preceding two sections, the interview is probably the most important tOOl in individual or group assessment. It Offers an active, dynamic situation in which the interviewer is both participant, Observer, and possibly agent Of change. 73Wynne, "The Study Of Intrafamilial Alignments and Splits . . .," p. lOu. #5 In the diagnostic or early phase Of treatment, we devise a number of hypotheses about what the problem or problems are that face the particular family. These come out of material from interviews, subjective experiences Of the interviewer, and are based upon some theoretical foundation. Another source of information is Offered through Objective methods of interaction analysis. Several writers have attempted to describe a family in interaction terms from an Objective standpoint. One of these is Jules Henry. He points out that the value Of interaction analysis is that it integrates material from diverse sources and puts it into Objective form. Furthermore, relation- ships are objectively summarized, and a picture is provided of what is being dealt with. Validation is described as being made possible (two analysts may code the same material in order to see if they come out with the same material or an Observer may live in the home although this is regarded as highly unlikely). Moreover, Henry states that "in the clinic the therapist must seek to manipulate as many factors as he can. It is imperative, however, so it seems to me, to sharply reduce the number of factors one manipulates in research. Meanwhile one must avoid so reducing the number Of factors that one robs the data of richness and meaning. I believe that the inter- aotional analysis meets the scientific requirement of delineation of file, while it remains the core of meaning so necessary to clinical interpretation."7u Henry defines an interactional system as "a relatively permanent rela- tionship between individuals who mutually stimulate one another to response."75 He then describes how such systems can be codified either mathematically or by Jules Henry, "Family Structure and the Transmission of Neurotic Behavior," American Journal of Orthopsychiatry, 21:59, 1951, p. 818. 75Ibid., p. 801. '46 lettering. Furthermore, he describes each system as having an emotional quality which in general differs from others in Operation. The principle is also stated that: "There is a differential transmission Of traits depending on the field of forces."76 Other authors have tried a trait approach to describing family inter- action. Jan Ehrenwald is typical in his use Of this method. The Inventory of Thirgy Traits and Attitudes is used by Ehrenwald to describe patterns 77 of interaction within family pairs and in a family as a whole. A method which the writer has not found used in describing family interaction, which is relatively easy to administer is the sociometric technique. In fact, the writer was surprised with the present emphasis on the family that the sociometric method had not been adapted by some social scientist in this area. Sociometric techniques could provide information that would be useful in establishing data about family patterns Of inter- action. The remainder Of this section shall be devoted to a discussion of socio- metric testing. The applicability Of the sociometric method for family diagnosis is based upon the concept Of the family as a group. Since the sociometric method was developed by small group theorist for Obtaining infor- mation about social interactions among groups of people such an application to a family group should be Obvious. Northway78 has demonstrated the extent to which sociometry has cut across lines of traditional subject matter areas, that is, sociology, psychology, and 76 Ibid., p. 808. 77Jan Ehrenwald, "Family Diagnosis and Mechanisms Of Psychosocial Defense," Family Process, Vol. 2, NO. 1, (March 1963) pp. 121-131. Mary L. Northway, "Sociometry and Some Challenging Problems of Social Relations," Sociometry, 9, NO. 2-3, 1995, pp. 197-198. #7 education. Why not then utilize such an adaptable instrument for the purpose of Obtaining diagnostic information in casework practice with families? The sociometric test developed from Moreno's idea of measuring inter- personal relations as reflected by the choice patterns of individuals in social groups. By 1939 a number of choice criteria had been applied in a number Of social situations. Practical experience with socionetric testing has indicated that the test should be primarily for the subject, instead Of the tester. It is reasoned from this that interpersonal relationships are best revealed when those tested are assured Of consequences Of their actions, "when the results of the test are or can be put into immediate Operation."79 (Of course, in the treatment context, the clients would have the assurance that the therapist is Obtaining important information which is to be used for their benefit.) Furthermore, sociometric tests may be supplemented by individual interviews in which clarification of expressed choices may be obtained.80 It is therefore conceived that the sociometric test is primarily of interest to the subject, and the adaptation of this tool becomes more plausible in terms of application as a diagnostic instrument when the entire family is focused upon. Essentially, the methodological contribution of the sociometric test has been that of the measurement Of interpersonal and intergroup relations. In terms Of Obtaining information about family interpersonal relations or interaction, it could be used for two purposes: (1) to provide information regarding an individual's acceptance, rejection, or isolation by other family members of the group, and how the various individuals feel toward each other, 79J. G. Franz, "Survey of Sociometric Techniques, with an Annotated Bibliography,” Sociometgy, 2, NO. n, 1939, p. 77. 80 Ibid., p. 78. 48 and; (2) to Obtain data about family group structure and processes in terms of networks Of communication. Mary L. Northway in her book A Primer Of Sociometry describes how to design and administer a sociometric test.81 Generally, in designing a test, three or four areas are selected in which members could have a real Opportunity for associating. These areas are made the basis for the test, and are called criteria for association. Each question is put in such a way that the individual is asked to name that person or persons within the group with whom he would choose to associate on the basis of each criterion. It is noted by the author that a sociometric criterion should be stated in the conditional mood. In choosing criterions, the author suggests that for usual sociometric situations tests using three criteria and allowing three choices be used. The explanation for this is that by using the same number of criteria and choices the sociometric results are more directly comparable without statistical equating. Northway states that "negative” choices are not generally used in most modern sociometric tests; however, in a family sociometric design, there may be some indication for the use of this kind of choice. The “negative” choice is useful in distinguishing between those who are simply not chosen and those who are actively rejected by the group. The above discussion of sociometry and its practical utility for family diagnosis has been exploratory in nature. The designing Of a sociometric test for family diagnosis would be another research project in and of itself. Such an instrument, as has been indicated, would be a worthwhile endeavor in terms of the use it could be put to in clinical casework practice. In conclusion, this chapter has been devoted to an exploration Of the various methods Of Obtaining diagnostic information about families. These 81 Mary Northway, A Primer of Sociometry, (Toronto: University Of Toronto Press, 1952). 1+9 were multiple client interview methods, the subjective experience of the family interviewer, and objective methods of interaction analysis. One area which has been passed over in this chapter on family diagnosis is the problem of a lack Of a useful classification system for disorders in the interaction within families which lead to problems in individual adaptation. There are a number of articles on frameworks for understanding family dynamics which could have been included in this chapter;82 however, for most intents and purposes, the kind Of information has already been discussed under the various methods in assessment. This statement, in itself, is probably indicative Of our present level Of sophistication in family diagnosis, i.e. we are presently at the descriptive level in our present stage of practice. 82Ackerman and Behrens, "A Study of Family Diagnosis,” p. 72. See also: Ackerman, The Psychodynamics of Family Life, pp. 138-145, and; Viola W. Weiss and Russell R. Monroe;i'A:Framewsrk fOr Understanding Family Dynamics: Part I," Social Casework, (January 1959) pp. 7-8. Chapter III FAMILY TREATMENT The Family Therapist C. F. Midelfort has treated schizophrenia, depression, paranoid illness, personality disorders, character neuroses, and psychoneuroses through family therapy. He has the following statement to make about the attributes which must characterize a family therapist: . . .must be human and willing to be as honest, responsible, well as he hopes and expects the patient and family to be. He must see and experience the various mental illnesses from within and without, and he must find means and methods to discover the truth and normalcy within all his patients, no matter what their psychopathology. Family therapy, based on a concept Of the family as the unit Of illness in which illnesses exist in balance, isBSUCh a means and method to a better understanding Of man. This is a good summary statement to begin with in our discussion of the family therapist. Probably a prerequisite to all other qualities, a family therapist should be genuine in his approach to a family. Midelfort partially portrays this when he refers to being "human”, "honest," and "responsible." It is the quality of genuineness on the part of the therapist which encourages freedom in communication which is essential to the therapy. Being genuine in the therapy session should enable the therapist to insist upon minimal conditions and limits within which the group members can eventually take the risks Of free communication, and also state his expectations as to therapy sessions and stability in group composition. In other words, there should be no pretentions or affectations as tO the purpose of the relationship 83C. F. Midelfort, The Family in Psychotherapy, pp. 199-200. -50- 51 which is being embarked upon in the therapy sessions. The family therapist, by consensus Of leading workers with families, is an active participant. He moves directly into the families attempts to deal with current problems. The emphasis is usually upon immediate distress, tensions in family interaction, and present conflicts and disablements. Frances Scherz offers a brief and adequate description of what the family caseworker does in the interview. This is as follows: 1. Any intervention by the worker through comments, Observa- tions, or questions, should be done in terms Of family interaction. 2. The worker should occupy a position Of empathic neutrality. 3. By intervening at appropriate points, the worker lets the participants know that he will not permit one family member to destroy another in the use of destructive defenses, or to control the interview. u. The nonverbal communication that goes on in the interview . . .Ought tO receive as much of the worker's attention as the specific content of what they say. 5. As treatment progresses, the caseworker must be alert to evidences that the participants are beginning to turn to each other, rather than to him in their attempts to understand each other's needs and ways of operating. an In regards to the second point, Scherz mentions that by the worker con- centrating on the essential meaning and significance of what is being said, he can tend to reduce the frequency of transference and countertransference problems. This is partially due to the fact that the worker does not become a third person in a triangle, but remains identified with the group. What is implicit in the above statements is the supportive function Of the relationship being provided by the therapist. There are several values in this support. One is that it reduces excess anxiety and encourages security and comfort. This enables the group members to feel that it is all right to have feelings, to express them, and not be fearful Of retaliation 81‘Frances H. Scherz, ”Multiple-Client Interviewing: Treatment Implica- tions," Social Casework, (March 1962) pp. 124-125. 52 or embarrassment. Another benefit is that the group members come to gain assurance that they can be helped, and begin to develop confidence that they can OOpe with the problems that face them. Another worth of support is that the members begin to broaden their horizons and stereotyped patterns of adaptation begin to give way to other viewpoints Of how to handle problems. Conversely, if the group or certain members therein, have been impulsive in handling problems, they might learn how to develop controls for dealing with stress or crises. The crux of family treatment rests upon the family therapist's ability to recognize strengths in the group and its members. It is also important to be aware of weaknesses and limitations. However, the test of con- structive casework often rests in the ability of the worker to acknowledge and facilitate emotional growth based upon the positive attributes of the personalities involved in the group. This is a difficult and Often challenging task with which the therapist is faced. Acknowledging and facilitating the growth Of the clients can Often be complicated by countertransference or unconscious feelings of the therapist. A comment by Savage, in his work with schizophrenic patients, also seems applicable to casework treatment with family groups as well as individuals. This is: . . . the innordinate investment of time and energy coupled with the scant return often reinforce the analyst's tendency to Obtain narcissistic gratification at the patient's expense, by reason of the patient's helpless dependence on him; he may unconsciously need the patient to remain sick, and, while consciously enjoining him to growth and development, may, unconsciously, not welcome it at all. These conflicting conscious and unconscious messages to the patient that he both grow up and remain a child at the same time place the patient in the pathogenic ”double-bind” situation described by Bateson, Jackson, and their colleagues. 850. Savage, "Countertransference in the Therapy of Schizophrenics," Psychiatry, Vol. 2M, 1961, p. 57. 53 In short, the subjective experiences or feelings of the caseworker are crucial in treatment as well as diagnosis.* The problem of transference is not as prevalent in family therapy as it is in individual casework treatment. This is true for several reasons. First, the caseworker, as has been indicated, is generally an active participant rather than being passive. Second, free association is not encouraged as a systematic procedure. In structural terms, the approach in group sessions is generally at the ego and superego level. Thus, we do not see a "depth" intrapsychic approach, as such, into unconscious motivations. However, this does not mean that we are not aware of psychodynamic material. Third, by intervening through comments, Observations, and questions at the interaction level and about reality factors in the relationships, transference tends to be diluted. Finally, generalization tends to dissipate transference, whereas personalization serves as a stimulus to it. This is partially due to the focus upon the group rather than the individual.86 The above comments do not mean that transference phenomena becomes of less importance to the family therapist. However, it is true that there are important built in mechanisms comprised within treatment Of families as groups which tend to dispel transferences. In concluding this discussion Of the family therapist, there has been no definition Offered of who a family therapist is, but those qualities and *See the discussion of the subjective experience of the family interviewer in Chapter II, pp. na-uu. 86This discussion was based in part upon an article which includes data, amongst other things, on how to regulate transference by Annette Garret, “The Worker-Client Relationship,” in Ego Psychology and Dynamic Casework, Howard J. Parad (Ed.), (FSAA, 1958) pp. 53-72. 5M attributes which characterize him were described. Also, some of the complexities which concern a family therapist have been elaborated upon. The question of who is or who does family therapy was not dealt with. This is due primarily to the fact that no single professional group has staked out family therapy exclusively as their own. However, social workers have long been noted for their work with families. Also, psychiatrists are increasingly becoming more interested in the family as a focal point for treatment. Criteria for the Use of the Family Interview Frances Scherz has identified four general hypothesis concerning family casework treatment which underlie the choice of the use of the multiple interview. These are as follows: The first hypothesis is that casework treatment is a therapeutic experience designed to free individual and family energy for use in OOping with problems that impede healthy development. The second hypothesis is that if treatment is to be effective, the key family members involved in the central problem or conflict must have a commitment to treatment. The third general hypothesis is that the family unit is always the focus of casework treatment. The fourth hypothesis is that the new focus on the family unit has resulted in changes in the treatment responsibilities Of the caseworker. These hypotheses were based upon the observational data of workers who have used group interviews. In the same article, Scherz describes six types of families and problems which have been helped by the use of the family interview method. The six 87Scherz, "Multiple-Client Interview . . .," pp. 120-121. 55 family types and related problems are described in the following quote: 1. 3. H. 5. 6. Multiple-client interviews are effective in the treatment of persons with acting-out character disorders when their central problem is diffi- culty in a marital or a parent-child relation- ship, and when the first goal Of treatment is to help them examine their role behavior. The use of multiple-client treatment interviews with neurotic parents of phobic children is a fertile field for investigation . . . found that . . .hostile-dependent tie between mother and child is loosened . . .when the parents are first treated through joint interviews. Multiple-client interviews may also be useful for families in which the crucial problem is the chronic illness or congenital handicap of one family member. When the worker decides that the first treat- ment aim should be to help family members improve their role functioning or alter their patterns of communication, the multiple-client interview can be a highly effective treatment medium. Individuals who cannot tolerate examining their personal problems or do not have emotional energy to invest in such an examina- tion Often respond best to the multiple-client interview technique. Finally, certain chaotic family situations in which family members are unable to face their personal problems may respgnd best to the multiple-client interview. 8 Four contraindications are also given for the use of multiple-client inter- views: 1. When family members obviously derive consistent and major gratification from supporting each other's destructive defensive maneuvers, the worker may find it necessary to treat them through individual rather than multiple- client interviews. 331bid., pp. 122-123. 56 2. When the neurosis or the character disorder of one family member produces the crucial family conflict to which other members are reacting, individual treatment is needed . . . may be preferred method. . . may serve as a pre- liminary to involving other family members in treatment. 3. When a person is overwhelmed by an intra- personal anxiety Or is inordinately fearful of revealing himself to other family members. 4. When the worker wants to secure historical data to further his diagnostic understanding, he may find it more economical to use individual interviews.89 Midelfort does not make the distinctions that Scherz does in determining whether or not family interviews should be the treatment method Of choice. He uses individual therapy along with family therapy. He believes that exclusive use Of individual therapy will only further distance the individual from his family. The main reason Offered for individual therapy is that of overcoming the individual's unconscious and subjective blocks or defenses against family therapy or group activity. The writer's only criticism of Midelfort's viewpoint is that sometimes the caseworker may want to distance the individual from his family. This is particularly true where a family may derive consistent and major gratifi- cation from supporting each other's destructive patterns. The General Goal and Focus of Family Treatment Sidney Berkowitz maintains that despite the fact that techniques will vary from case to case, "the goal is consistently that of effecting some degree of modification of adaptive behavior."90 Moreover, this is regarded 89Ibid., p. 123. 90Sidney Berkowitz, "Some Specific Techniques of Psychosocial Diagnosis and Treatment in Family Casework," Social Casework, (November 1955) p. nos. 57 by the author as being true of all casework. It is further contended that the difference between one case or another is a problem of degree. This approach is in opposition to the dichotomy set forth in the Scope and Methods report of the Family Service Association of America.91 In this report, the classifications Of maintaining adaptive patterns and modifying adaptive patterns are set forth. In practice, the dichotomy of maintaining adaptive patterns and modifying adaptive patterns seems unnatural. It does not do justice to the complicated, and complex subtleties of the applications of treatment techniques, sensitivi- ties Of relationship, or the dynamic of change regardless Of how minute. In stating the following goal of family treatment, the writer, as well as Berkowitz, is probably at odds with some leading writers in the field. However, it seems that the goal of family treatment is that of modifying adaptive behavior. The goal is Often enacted at the ego and superego levels of personality structure. Since personality structure (ego, id, superego) is dynamic, it may be conceived that a reaction at the ego or superego parts of the structure would influence each other and the regulation Of id impulses. Such being the case, it is difficult to view the classification Of main- taining adaptive patterns of behavior as applicable. Pollak and Brieland indicate that the initial focus in treating families "92 is upon their “most burdensome problem. Parad and Caplan also indicate in 91SCOpe and Methods of the Family Service Agency, (New York, FSAA, 1953). 92Pollak and Brieland, "The Midwest Seminar . . .," pp. 320-322. 58 their study Of the dynamics Of family behavior during crisis that intervention by a caseworker can have the most results for the least effort when this help occurs during the height of the family crisis.93 As casework treatment proceeds, the focus is primarily upon family interaction. As conceptualized in Chapter II, this interaction may be "inter- group interaction" or "extra-group interaction." In practice, there is no split of one kind of interaction from the other since it is hOped that as behavior in the family improves so will actions outside the group. TO conclude, the general goal of family treatment is that of modifying adaptive behavior. Also, the focus is initially upon the major concern Of the family. For the best long-term gains, the emphasis is primarily upon interaction amongst the family members within the group, as well as member and family interaction with society. Howard J. Parad and Gerald Caplan, "A Framework for Studying Families in Crisis," Social Work, Vol. V, NO. 3 (1960) pp. 3-15. 59 CONCLUSION One of the major Objectives of the social work profession is the enabling of clients in experiencing satisfying relationships. The manner in which this aim is implemented has been an area of contention amongst practitioners. The issue involved is whether the focus should be upon the individual client, or his social conditions. The viewpoint has been expressed in this study that the family may be an appropriate focal point from which to view problems in relationships, and also treat them. The value Of this has been suggested as that of aiding in the elimination of perceiving man in dichotemized terms. The implications of this statement are manifold, and have been indicated throughout this study. Concepts relevant to family diagnosis and treatment were discussed in Chapter I. After the concepts were derived from the literature survey, it was possible to devise four categories or divisions into which these concepts could be grouped: family structure, family inter-group interaction, family extra-group interaction, and family management of crisis. The importance Of the formulation Of four major divisions is twofold: (1) other concepts can be meaningfully added and enlarged upon, and; (2) the concepts within the present study can be explored in more depth in future studies from this central design. The methods of acquiring diagnostic information about families were discussed in Chapter II. These were: multiple interview methods, the subjective experience of the family interviewer, and the Objective methods of interaction analysis. The problem of a lack of a useful classification 60 system for disturbances in the interaction within families which lead to problems in individual adjustment was specified in this chapter. Also, the discussion in this chapter had the intrinsic value of indicating our present level of knowledge about family diagnosis, i.e., we are currently at the descriptive level in practice and research. Family treatment was discussed in Chapter III. Three factors were considered: the family therapist, criteria for the use of the family interview, and the general goal and focus of family treatment. Several conclusions were made. First, who does family therapy has not been defined. However, the attributes of a family therapist have been mentioned in the literature, and have been briefly discussed in this project. Second, criteria for the use of the family interview were not discussed in much detail. The only conclusion that can be reached at this point is that much more research is needed in this area. The work Of Frances Scherz probably Offers the best formulation of criteria presently available. Finally, the goal of family treatment was viewed as being that of modifying adaptive behavior. The focus is upon the major concern Of the family, and how crisis is managed. For lasting long-term gains, however, the emphasis Often needs to be upon the interaction amongst the family members within the group, and family unit and member interaction with society. Three problem areas in family diagnosis and treatment are viewed as taking precedence in further research efforts: (1) The problem of theoretical reformulation. Presently, there is a need to reformulate or formulate concepts so as to bridge the gap between the individual and environment. As suggested in this project, there is a beginning in this direction; 61 (2) The problem of testing and operationalizing concepts. We must have the courage to re-appraise and eliminate or re-define vague, meaningless, and misapplied concepts. Involved in this problem is the difficulty of developing methods of study, and a common language or vocabulary for researchers as well as practitioners. Both are dependent upon the work of the other. The researcher often looks for insights from the practitioner, and the practitioner depends on the researcher for findings which may be used to improve practice. (3) The problem of application. The central question facing the social worker is: How can we be most effective in enabling constructive interaction amongst family members leading to the development of inter- personal competence Of the various individual members? The answer to this question seems to rest, in part, upon the following considerations: (a) developments in the preceding two problem areas; (b) the construction and validation of a useful classification system for disorders in the interaction within families which lead to problems in individual adapta- tion; (c) the formulation and rigorous examination Of criteria indicating or contraindicating the use of family interviews, and; (d) the collection, evaluation, and systematization of practice methods so that they can be transmitted to students interested in receiving training in the techniques of family therapy or casework. BIBLIOGRAPHY Books Ackerman, Nathan W. The Psychodynamics of Family Life: Diagnosis and Treatment of Family Relationships, New York: Basic BOOks. 1958. Ackerman, N. W., Beatman, F., and Sherman, 8. Exploring the Base for Family Therapy, New York: FSAA, 1961. Aptekar, H. H. The Dynamics of Casework and Counseling, Houghton Mifflin Company, 1955. Bach, George. 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