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The use of strategic/systemic methods in a residential treatment home Pare, Timothy 1988

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THE USE OF STRATEGIC/SYSTEMIC METHODS IN A RESIDENTIAL TREATMENT HOME By TIMOTHY PARE B.A., Concordia University; Montreal, 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1988 ( c ) Timothy Pare , 1988 In p r e s e n t i n g this thesis in part ial f u l f i lmen t o f t h e requ i remen ts fo r an a d v a n c e d d e g r e e at t h e Univers i ty o f Bri t ish C o l u m b i a , I agree that t h e Library shall m a k e it f ree ly avai lable fo r re ference a n d s tudy . I f u r the r agree that permiss ion fo r ex tens ive c o p y i n g o f th is thesis fo r scho lar ly p u r p o s e s may b e g r a n t e d by t h e h e a d o f m y d e p a r t m e n t o r by his o r her representa t ives . It is u n d e r s t o o d that c o p y i n g o r pub l i ca t i on o f th is thesis f o r f inancia l ga in shall n o t b e a l l o w e d w i t h o u t m y w r i t t e n permiss ion . D e p a r t m e n t T h e Un ivers i ty o f Brit ish C o l u m b i a 1956 M a i n M a l l Vancouver , Canada V 6 T 1Y3 nF.fin/ft-n ABSTRACT The systemic orientation to behavioral change and the use of paradoxical interventions has been predominantly associated with the family therapy movement. Recently p r a c t i t i o n e r s have been experimenting with the use of strategic/systemic methods in r e s i d e n t i a l treatment centers, schools, and hospital i n -patient settings. The l i t e r a t u r e suggests that these interventions may be i d e a l l y suited for oppositional or reluctant c l i e n t s who r e s i s t cooperating in the treatment process. This thesis provides a case study description of an adolescent treatment home which has developed a strategic/systemic approach to r e s i d e n t i a l care. The implementation of a systemic perspective to r e s i d e n t i a l treatment required substantial changes to t r a d i t i o n a l c h i l d care philosophy and practi c e . These changes are described and discussed and actual intervention examples are presented which help to illuminate t h i s novel approach to r e s i d e n t i a l treatment. i i i TABLE OF CONTENTS ABSTRACT i i ACKNOWLEDGEMENTS i i i CHAPTER I - INTRODUCTION 1 NEED FOR THE STUDY 4 BACKGROUND TO THE PROBLEM , 5 1) The Ide n t i f i e d (IP) Patient 8 2) The Surrogate Parent Problem 9 3) The Problem of Resistance 11 4) The Problem of Control and D i s c i p l i n e 12 CHAPTER II - LITERATURE REVIEW 17 TRADITIONAL THEORIES OF RESIDENTIAL TREATMENT 17 PSYCHOANALYTICAL RESIDENTIAL TREATMENT 18 BEHAVIORAL RESIDENTIAL TREATMENT 3 2 GUIDED GROUP INTERACTION 37 THE RE-ED APPROACH 42 THE STRATEGIC/SYSTEMIC APPROACH 44 CHAPTER III - METHOD OF STUDY 75 THE CASE STUDY AS A METHOD OF RESEARCH 75 THE SINGLE CASE DESIGN 79 DATA COLLECTIONS 81 DATA ANALYSIS 84 LIMITATIONS 85 CHAPTER IV - RESULTS 87 THE DEVELOPMENT OF A SYSTEMIC APPROACH 87 RELATIONSHIPS 91 RESISTANCE 98 RULES AND CONSEQUENCES 101 THE PHYSICAL SETTING 104 THE STAFF 105 iv THE RESIDENTS 1 0 8 INTERVENTIONS I l l FORMULATING INTERVENTIONS 1 1 5 DELIVERING INTERVENTIONS 1 1 8 CASE EXAMPLES 1 2 1 Case Example # 1 - Caren 1 2 1 Case Example # 2 - Sandra 1 2 5 Case Example # 3 - Lisa 1 3 2 Case Example # 4 - Shannon 1 3 5 Case Example # 5 - Tina 1 3 8 CHAPTER V - DISCUSSIONS AND CONCLUSIONS 1 4 2 REFERENCES 1 6 5 V ACKNOWLEDGEMENTS I would like to thank a l l of the treatment home staff for their help and encouragement. Special thanks goes to Diane and Jacqueline for their val-uable time. 1 THE USE OF STRATEGIC/SYSTEMIC METHODS IN A RESIDENTIAL TREATMENT HOME CHAPTER I - INTRODUCTION Residential settings for the treatment of childhood and adolescent behavior problems were f i r s t developed i n the early 1 9 5 0 * s . Buno Bettelheim, F r i t z Redl, and Moris F r i t z Mayer are considered the founders of the r e s i d e n t i a l or milieu approach to treatment (Whittaker, 1 9 7 9 ) . These t h e o r i s t s , who were a l l members of the psychoanalytic school, were of the opinion that c l i n i c a l treatment, where a c l i e n t i s seen i n an o f f i c e setting once or twice a week, provided limited effectiveness for the c h i l d and adolescent population. In order to provide a more potent treatment approach they began to develop community based therapeutic environments. These therapeutic environments had a common goal of providing on-going, structured treatment i n a setting removed from the c h i l d or adolescent's family (Klein, 1 9 7 5 ) . Today the use of therapeutic environments for the treatment of childhood and adolescent problems i s r e l a t i v e l y widespread. There are currently numerous r e s i d e n t i a l treatment approaches, each with t h e i r own p a r t i c u l a r philosophical ori e n t a t i o n . With some of these approaches the theoreti c a l foundations can be traced back to the o r i g i n a l formulations of the psychoanalytic theorists mentioned above. Other approaches have based t h e i r treatment philosophy on more contemporary ideas adopted from s o c i a l i n t e r a c t i v e , educational or behavioral theories (Brendtro & Ness, 1 9 8 3 ) . The systemic family therapy movement, which includes strategic and paradoxical therapy, has recently taken a leading role i n the introduction of new methods for f a c i l i t a t i n g behavior change. Proponents of t h i s novel approach have proposed a r a d i c a l l y d i f f e r e n t view of problem formation and resolution (Watzlawick et a l . , 1 9 7 4 ) . This r a d i c a l l y d i f f e r e n t view, which may be c a l l e d the systemic orientation, challenges the t r a d i t i o n a l causal-mechanistic view of phenomena and suggests instead a theory of c i r c u l a r c a u s a l i t y (Palazzoli et a l . , 1978). C i r c u l a r causality assumes that present behavior i s not determined by previous events i n a cause-and-effect manner but instead i s a product of an individual acting on and being influenced by a system of which he i s a member. Unt i l quite recently the application of t h i s new systemic orientation took place almost exclusively within the s p e c i a l i z a t i o n of family therapy. Watzlawick and his associates at the Mental Research Institute (MRI) ( 1 9 6 7 , 1974), Pa l a z z o l i and the Milan group (1978a), and Haley ( 1 9 6 3 , 1 9 7 6 ) are considered the leading proponents of the strategic/systemic treatment of f a m i l i e s . These t h e r a p i s t s have used p a r a d o x i c a l i n t e r v e n t i o n s as the primary v e h i c l e f o r i n t r o d u c i n g change w i t h i n d y s f u n c t i o n a l f a m i l y systems. P a r a d o x i c a l i n t e r v e n t i o n s are noted as the d i s t i n g u i s h i n g f e a t u r e of the s y s t e m i c / s t r a t e g i c approach (Weeks & L'Abate, 1982). Although the use of p a r a d o x i c a l i n t e r v e n t i o n s has predominantly been a s s o c i a t e d with the f a m i l y therapy context, some r e s e a r c h e r s have i n v e s t i g a t e d the p o t e n t i a l f o r u s i n g these i n t e r v e n t i o n s under d i f f e r e n t c ircumstances. Numerous cases have been r e p o r t e d where s p e c i f i c b e h a v i o r a l problems, such as insomnia, o b s e s s i o n a l thoughts and u r i n a r y r e t e n t i o n , have been t r e a t e d on an i n d i v i d u a l b a s i s u s i n g v a r i o u s p a r a d o x i c a l i n t e r v e n t i o n s (Ascher, 1979; Solyom et a l . , 1972; Turner & Ascher, 1979; Kolko, 1984; M i l a n & Kolko, 1982). Stanton (1981b) reviewed the l i t e r a t u r e on p a r a d o x i c a l psychotherapy and r e p o r t e d t h a t t h i s approach has been used i n a wide v a r i e t y of cases. The p r e s e n t i n g problems i n c l u d e d , among o t h e r s ; a l c o h o l i s m , anorexia and e a t i n g d i s o r d e r s , a d o l e s c e n t problems, a n x i e t y , delinquency, d e p r e s s i o n , m a r i t a l problems, phobias, s c h i z o p h r e n i a and temper tantrums. The l a t e s t psychotherapy i s settings other i n n o v a t i o n i n the f i e l d the a p p l i c a t i o n of p a r a d o x i c a l than the c l i n i c i a n ' s o f f i c e . of paradoxical techniques i n Some creative 4 p r a c t i t i o n e r s have been experimenting with the use of paradoxical interventions in r e s i d e n t i a l treatment centers, schools, and hospital in-patient settings (Jessee & L'Abate, 1 9 8 0 ; Bergman, 1 9 8 0 ; Jessee et a l . , 1 9 8 2 ; Williams & Weeks, 1 9 8 4 ) . In response to the promising results reported by pr a c t i t i o n e r s of the systemic approach, coupled with a growing d i s s a t i s f a c t i o n for the more t r a d i t i o n a l approaches to r e s i d e n t i a l treatment, a Vancouver based home decided to introduce some strategic/systemic methods into t h e i r treatment philosophy. The purpose of t h i s thesis i s to describe the use of these strategic/systemic methods and to provide examples of interventions that may or may not be e f f e c t i v e within a r e s i d e n t i a l treatment setting. NEED FOR THE STUDY There are two primary reasons why a study of t h i s sort i s needed at t h i s time. The f i r s t reason has to do with the r a d i c a l l y d i f f e r e n t perspective of problem formation and resolution proposed by the proponents of the systemic orient a t i o n . This new perspective must be investigated further in order to more f u l l y develop a comprehensive theory of human behavior and change. The present study i s a description of the p r a c t i c a l application of t h i s new approach and the t h e o r e t i c a l concerns that become evident upon i t s implementation. 5 Secondly, a study of t h i s sort i s needed as a means for investigating potential improvements to the r e s i d e n t i a l treatment f i e l d . Front l i n e workers in a r e s i d e n t i a l treatment home are faced with the extremely d i f f i c u l t task of tr y i n g to treat individuals who openly r e s i s t and a c t i v e l y sabotage the treatment offered to them. Techniques to increase the front l i n e worker's effectiveness as a f a c i l i t a t o r of change need to be developed i n order to enhance the impact of the overall treatment environment. In summary, then, there i s both a theoretic a l and p r a c t i c a l need for the present study; from a the o r e t i c a l standpoint, the consequences of applying systemic methods i n a r e s i d e n t i a l setting w i l l be discussed, and from a p r a c t i c a l standpoint, the potential use of new interventions in a r e s i d e n t i a l setting w i l l be investigated. BACKGROUND TO THE PROBLEM The treatment home which i s the subject of t h i s thesis has a mandate to provide r e s i d e n t i a l treatment for up to seven adolescent g i r l s between the ages of twelve and nineteen. The adolescents are expected to remain i n treatment for three months, with a maximum stay of six months. However these are simply guidelines for suggested treatment duration and they are not r i g i d l y enforced. There are eleven f u l l time s t a f f members employed at the treatment home (hereafter c a l l e d Vanhouse). Six people are employed as c h i l d care workers (usually three men and three women), two as overnight workers, two as family workers and a supervisor. Prior to the introduction of strategic/systemic methods into the Vanhouse treatment plan the approach was predominantly relationship-based. This relationship-based approach, which had much i n common with the Redl ( 1 9 5 2 ) approach to be described l a t e r , r e l i e d on strong supportive relationships between s t a f f and children to act as an agent for change. In addition the s t a f f attempted to provide clear and consistent structure and used confrontation to set l i m i t s on the adolescents' inappropriate behavior. Many of the Vanhouse s t a f f expressed d i s s a t i s f a c t i o n with the approach to treatment that was employed p r i o r to the introduction of the strategic/systemic methods. Open c o n f l i c t between s t a f f and residents was reportedly quite common and resistance on the part of the adolescent g i r l s was the norm. At t h i s time some of the s t a f f began to investigate the strategic/systemic l i t e r a t u r e on problem formation and resolution. Two sources were of s p e c i f i c i n terest; Watzlawick's ( 1 9 7 4 ) work with the Mental Research I n s t i t u t e and Pala z z o l i ' s (1978a) research with the Milan group. The Vanhouse s t a f f discovered through t h e i r investigation that, from a systemic perspective, the very idea of providing treatment to an individual removed, from the family unit was countertherapeutic. From a systemic perspective an individual's symptomatic behavior i s embedded in dysfunctional family patterns and therefore the ideal unit of treatment i s the family i t s e l f (Slive, 1987). However, there are situations where the removal of the c h i l d from the family home becomes a necessity. For example, some family environments become highly destructive where violence, s u i c i d a l behavior or sexual abuse can severely threaten the c h i l d ' s well being. The Vanhouse s t a f f decided that to provide e f f e c t i v e systemically oriented treatment they would have to work in such a way as to avoid disempowering the adolescent or her family, and seek to involve them a l l i n the solution to the family's problems. Four s p e c i f i c issues of concern become apparent when attempting to provide treatment in a setting removed from the adolescent's family. These four issues, which are i d e n t i f i e d below, e s s e n t i a l l y represent some inherent complications or theoretical inconsistencies that a r i s e when an attempt i s made to treat adolescents in a r e s i d e n t i a l s e t t i n g . The challenge that faces any program i s to come to grips with these issues and to provide solutions which are consistent with the o v e r a l l goals of the treatment philosophy. The issues are as follows: 8 1) The I d e n t i f i e d P a t i e n t (IP) Problem The i d e n t i f i e d p a t i e n t i s the i n d i v i d u a l i n the f a m i l y who has been i d e n t i f i e d , u s u a l l y by the pa r e n t s , as the one who has the problem and needs t o change. From a systemic p e r s p e c t i v e the "problem" i s i n t e r a c t i v e , i n v o l v i n g the whole f a m i l y u n i t , and t h e r e f o r e i t i s e p i s t e m o l o g i c a l l y i n c o r r e c t t o i d e n t i f y any one i n d i v i d u a l as the " p a t i e n t " . By a c c e p t i n g the ad o l e s c e n t I.P. i n t o the home f o r treatment the s t a f f are i m p l i c i t l y agreeing t h a t the s o l u t i o n to the f a m i l y problems may be r e s o l v e d by " c u r i n g " the adolescent i n i s o l a t i o n from f a m i l y i n t e r a c t i o n . T h e r e f o r e the attempted s o l u t i o n t o the f a m i l y problem, i . e . p l a c i n g the c h i l d i n ca r e , adds t o the problem by str e n g t h e n i n g the idea t h a t one person i s a t the r o o t of the problem. An i s s u e t h a t i s a s s o c i a t e d with the I.P. problem, and which has been i d e n t i f i e d by S l i v e (1987), i s t h a t of "treatment sabotage". Now t h a t the I.P. has been i s o l a t e d as the cause of the f a m i l y problem the parents t u r n t o the treatment s t a f f and ask f o r a cure. However, p a r a d o x i c a l l y , i f the s t a f f succeed i n a "cure" then the parents f e e l t h a t they themselves must somehow be incompetent as c a r e t a k e r s . There are two s o l u t i o n s t h a t the f a m i l y may attempt to r e s o l v e t h i s 9 problem of appearing incompetent. Both s o l u t i o n s i n v o l v e an attempt to sabotage treatment. With the f i r s t s o l u t i o n the parents w i t h h o l d important i n f o r m a t i o n t h a t might h e l p the s t a f f i n t h e i r treatment p l a n or they r e f u s e to accept t h a t any p o s i t i v e b e h a v i o r a l changes have o c c u r r e d while i n treatment. By not c o o p e r a t i n g with the s t a f f and by r e f u s i n g t o acknowledge or encourage p o s i t i v e s i g n s of change the parents p r o t e c t t h e i r i d e n t i t y as "good p a r e n t s " . The second way t h a t treatment may be sabotaged i n v o l v e s the l o y a l t y of the I.P. The I.P., who g e n e r a l l y has a g r e a t amount of hidden l o y a l t y t o her p a r e n t s , may r e s i s t improving her behavior to a v o i d making her parents look l i k e f a i l u r e s . T h i s l o y a l t y l i k e l y i n c l u d e s r e s i s t i n g whenever s t a f f take on a r o l e t h a t i s s i m i l a r to t h e i r p a r e n t s ' r o l e . These sabotage attempts are good examples of how the f a m i l y hangs on to the s t a t u s quo and t h e i r shared world view (Minuchin, 1974). 2) The Surrogate Parent Problem T h i s second t h e o r e t i c a l problem which i s a s s o c i a t e d with r e s i d e n t i a l care has been examined w e l l by Perry et a l . (1984) i n t h e i r a r t i c l e , " Separation and Attachment: A S h i f t i n P e r s p e c t i v e " . T r a d i t i o n a l approaches to r e s i d e n t i a l treatment 1 0 stress the importance of developing strong bonds between s t a f f and children as an active agent for change (Bettelheim, 1 9 7 4 ; Jones, 1 9 8 0 ; Brendtro & Ness, 1 9 8 3 ) . If the goal from a systemic perspective i s to f a c i l i t a t e problem resolution within the family unit, then bonding between the s t a f f and adolescent may, to some extent, be countertherapeutic. The rationale for t h i s i s that i f the adolescent turns to the s t a f f to meet t h e i r intimacy needs then the s t a f f may act to block the i n t e r a c t i o n that might have occurred between the family and the adolescent. The fact i s that a c h i l d care worker i s not, and can never be, the c h i l d ' s parent. He or she i s not a simulation, a r t i f i c i a l or imitation parent. Unfortunately many adolescents in care are developmentally at a stage where given the opportunity they w i l l "attach" themselves to the s t a f f members and, in turn, "detach" from t h e i r parents and fa m i l i e s . As Perry et a l . ( 1 9 8 4 ) state, adolescence i s a time when separation and attachment issues surface and the res u l t i s often a disturbed, turbulent environment. This unstable s i t u a t i o n , given time, w i l l more than l i k e l y resolve i t s e l f as the adolescent develops an i d e n t i t y separate from the family unit. However, i t i s pr e c i s e l y at t h i s time, when the adolescent i s beginning to tackle the developmental i d e n t i t y issue, that the community resources become involved and r i s k complicating or postponing the resolution of t h i s issue. 11 The point to be made here i s that placement may exacerbate the "problem" by disturbing the natural process of separation and attachment that occurs during an adolescent's development. For t h i s reason r e s i d e n t i a l s t a f f must take a long and hard look at t h e i r own behavior and i d e n t i f y how they can best f a c i l i t a t e the natural process mentioned above and avoid any action on t h e i r part that may contribute to the problem. Perry et a l . (1984) give examples of how r e s i d e n t i a l treatment interventions disempower the family as a unit by creating a struggle between the family, adolescent and s t a f f . The adolescent i s said to be "triangulated" i n a process where the s t a f f and the family are e s s e n t i a l l y p u l l i n g in opposite d i r e c t i o n s . As we can see t h i s "surrogate parent" problem i s a serious t h e o r e t i c a l concern for any r e s i d e n t i a l treatment home. 3) The Problem of Resistance The t h i r d major obstacle to e f f e c t i v e treatment i n a re s i d e n t i a l setting has to do with the phenomenon of c l i e n t resistance. This issue, which has a long history within the mental health f i e l d , i s esp e c i a l l y relevant when dealing with reluctant c l i e n t s . The r e s i d e n t i a l setting i s a unique treatment environment where the c l i e n t not only r e s i s t s 12 treatment but often does not even acknowledge that any problem exists in the f i r s t place. Recognizing that even under the best of circumstances people r e s i s t changing t h e i r behavior, i t ' s no surprise to discover that a reluctant c l i e n t , who i s also an adolescent and i s l i k e l y experiencing a l i f e c r i s i s , provides an immense challenge to those who are i n the po s i t i o n of administering treatment. Much of the c h i l d care worker's energy and thought i s taken up by t h i s task of dealing with resistance. Associated with the resistance problem i s the d i f f i c u l t y i n "reaching" the adolescent who lacks insight into her problem s i t u a t i o n . This incapacity may be due to poor language s k i l l s , conceptual s k i l l s , or repression. 4) The Problem of Control and D i s c i p l i n e The l a s t issue of concern arises from the necessity for the s t a f f to manage the behavior of the residents. At the very least the s t a f f must have enough authority to control behavior that threatens the safety of the adolescents in the home. If the s t a f f are required to put themselves i n a one-up position when i t comes to house rules, then t h e i r therapeutic role within the home i s c l e a r l y affected. 1 3 According to Dahms ( 1 9 7 8 ) ; It i s a maxim i n r e s i d e n t i a l programs that e f f e c t i v e treatment needs to be preceded by e f f e c t i v e control; that no treatment i s r e a l l y possible unless the disturbed, delinquent, or disorganized behavior of the c l i e n t population can be made responsive to s t a f f authority and contro l . (pg« 3 3 6 ) The problem here i s that t r a d i t i o n a l approaches to re s i d e n t i a l treatment generally employ a linear approach to resident behavior management. In other words, i f a resident f a i l s to cooperate with s t a f f requests, more "force" i s applied to overpower the adolescent and gain t h e i r cooperation. Dreikurs ( 1 9 6 4 ) has shown how easy i t i s to become involved i n power struggles with d i f f i c u l t young people. When s t a f f become involved in power struggles with residents the adult i s l i k e l y to display h o s t i l e or aggressive behavior. Such counter aggression i s always counter-productive because i t validates the adolescent's ex i s t i n g perception of the adult as a negative person. This question; control issue can be summarized in the form of a how can s t a f f exercise adequate control over residents without seriously jeopardizing t h e i r therapeutic role within the home? The four issues mentioned above are presented as roadblocks or challenges to the e f f e c t i v e treatment of adolescents in a r e s i d e n t i a l treatment setting. The new systemic approach introduced into the Vanhouse treatment program i s an attempt to tackle these roadblocks and provide a more e f f e c t i v e treatment environment. In order to accomplish t h i s two major changes were introduced into the treatment program. The f i r s t change involved providing family therapy sessions for the adolescents and t h e i r respective f a m i l i e s . The purpose for t h i s change was to involve the whole family as much as possible i n the process of change. The second major change was the use of strategic/systemic methods as the predominant mode for providing on-going treatment within the r e s i d e n t i a l s e t t i n g . This thesis i s a descriptive study of the use of these strategic/systemic methods in the Vanhouse treatment setting. The study i s a q u a l i t a t i v e , rather than quantitative, analysis of the interventions u t i l i z e d and the associated t h e o r e t i c a l issues that become1 evident upon t h e i r implementation. The s p e c i f i c questions addressed by t h i s thesis are: 15 1) How were the s t r a t e g i c / s y s t e m i c i n t e r v e n t i o n s formulated and d e l i v e r e d w i t h i n the r e s i d e n t i a l s e t t i n g ? 2) Based on the author's c l i n i c a l judgement as a p a r t i c i p a n t observer i n the home, which of the v a r i o u s i n t e r v e n t i o n s u t i l i z e d appeared t o be most s u c c e s s f u l and f o r what reasons? 3 ) What are the s i g n i f i c a n t c o n t e x t u a l v a r i a b l e s a s s o c i a t e d with the implementation of these i n t e r v e n t i o n s i n the r e s i d e n t i a l s e t t i n g ? 4) What are the comparative b e n e f i t s and drawbacks of u s i n g s t r a t e g i c / s y s t e m i c methods, as opposed to t r a d i t i o n a l methods, i n a r e s i d e n t i a l s e t t i n g ? The method of study chosen t o answer the above q u e s t i o n s was the case study approach. A c c o r d i n g to Y i n (1984), the case study method i s the re s e a r c h method of c h o i c e when a "how" or "why" q u e s t i o n i s being asked about a contemporary set of events, over which the i n v e s t i g a t o r has l i t t l e or no c o n t r o l . The case study takes a h o l i s t i c view of a phenomenon and attempts to i l l u m i n a t e the s i g n i f i c a n t v a r i a b l e s and make q u a l i t a t i v e statements concerning the r e l a t i o n s h i p between them. The pr e s e n t t h e s i s i s an example of a s i n g l e - c a s e r e s e a r c h d e s i g n . The evidence presented i s based on th r e e d i f f e r e n t sources of data c o l l e c t i o n ; documentation, i n t e r v i e w s and i n f o r m a t i o n obtained through the p a r t i c i p a n t o b s e r v a t i o n r o l e . The author of the t h e s i s was employed f o r s i x months as a p a r t -time c h i l d c a r e worker i n the home. T h i s p a r t i c i p a n t -16 observation role provided the author with a first-hand, i n -depth look at the approach to r e s i d e n t i a l treatment that was developing at Vanhouse. Chapter three of the thesis provides more information on the case study as a method of research. The following chapter provides a thorough review of the t r a d i t i o n a l approaches to r e s i d e n t i a l treatment as well as the strategic/systemic approach to problem formation and resolution. CHAPTER II - LITERATURE REVIEW TRADITIONAL THEORIES OF RESIDENTIAL TREATMENT In t h i s section four d i s t i n c t theories of r e s i d e n t i a l treatment w i l l be discussed; the psychoanalytic, behavioral, guided group, and re-education approaches. Once these four theories have been discussed, the s i g n i f i c a n t ingredients that make up r e s i d e n t i a l treatment w i l l be i s o l a t e d and examined separately. It i s important to keep i n mind that the purpose of t h i s review, of the t r a d i t i o n a l approaches to r e s i d e n t i a l treatment, i s to understand the context into which the systemic-strategic methods were introduced. Morse, Cutler and Fink ( 1 9 6 4 ) report that "many c h i l d care workers are atheoretical n a t u r a l i s t s " who base t h e i r work on t h e i r own personal theories and who are often quite successful at t h e i r job (Morse, Cutler, & Fink, 1 9 6 4 ) . In some treatment centres with a stated orientation, the workers rel y more on t h e i r personal bias to treatment while outwardly complying with the organization's expectations. Since c h i l d care workers tend to follow t h e i r own i m p l i c i t theories, i t becomes an enormous task to mold a service organization to comply with a p a r t i c u l a r philosophical orientation (Brendtro & Ness, 1 9 8 3 ) . Keeping 1 8 t h i s point i n mind, l e t us examine the f i r s t t r a d i t i o n a l approach; the psychoanalytic. PSYCHOANALYTICAL RESIDENTIAL TREATMENT The pioneers who f i r s t developed a r e s i d e n t i a l or M i l i e u approach to treatment for troubled children were a l l strongly influenced by psychoanalysis. These pioneers included Bruno Bettelheim ( 1 9 5 0 , 1 9 5 5 , 1 9 6 7 , 1 9 7 4 ; 1 9 4 8 with Emmy Sylvester), F r i t z Redl ( 1 9 5 7 with David Wineman, 1 9 5 9 , 1 9 6 6 ) , and Moris F r i t z Mayer ( 1 9 6 0 , 1 9 7 1 with Arthur Blum). These three prominent theori s t s attempted to apply basic psychoanalytic p r i n c i p l e s to the c h i l d ' s t o t a l l i v i n g environment. Bruno Bettelheim's work, as well as being influenced by psychoanalytic writings, was influenced by his experience as a prisoner in the Nazi concentration camps of Dachau and Buchenwald (Whittaker, 1 9 8 1 ) . From his prison experiences, he was able to see how strong the human s p i r i t can be i n overcoming even the most degrading of environments. During the years from 1 9 4 4 to 1 9 7 3 , he was the dire c t o r of the University of Chicago's Sonia Shankman Orthogenic School for emotionally disturbed children. His work at the Orthogenic school i s reported by himself in books such as "Love i s Not 1 9 Enough" ( 1 9 5 0 ) , "Truants from L i f e " ( 1 9 5 5 ) , "The Empty Fortress" ( 1 9 6 7 ) and "A Home for the Heart" ( 1 9 7 4 ) . Whittaker ( 1 9 8 1 ) describes Bettelheim's work as follows; While there i s much value and sheer b r i l l i a n c e , i t i s a d i f f i c u l t approach to put into operation. To be sure, his c l i n i c a l accounts are fascinating descriptions of what disturbed behavior i s l i k e , though i n my judgement, many are based on f a l s e assumptions and sheer speculation about the origins of childhood disorders. ( 1 9 8 2 p. 4 7 ) Although Bettelheim's work may not be considered a comprehensive treatment approached i n i t s own ri g h t , his influence had a great impact on the development of a milieu approach to treatment. His work r e f l e c t s a passion for d e t a i l with every aspect of the treatment environment considered for i t s therapeutic e f f e c t . The development of what he c a l l e d " t o t a l therapy" took into account the rules, routines, a c t i v i t i e s , s t a f f / c h i l d interactions and architecture of the treatment environment (Bettelheim, 1 9 7 4 ) . Another important contribution introduced by Bettelheim was his recognition of the importance of the front l i n e workers. This r e a l i z a t i o n , of the considerable therapeutic 2 0 impact imparted by workers in t h e i r day-to-day interaction with children, i s most evident in his l a t e r writings - es p e c i a l l y "A Home for the Heart" ( 1 9 7 4 ) . The t h e o r i s t whose name i s most commonly associated with the psychoanalytic approach to r e s i d e n t i a l treatment i s F r i t z Redl. Redl's book, "Controls from Within" ( 1 9 5 2 ) could be considered the basic textbook on r e s i d e n t i a l treatment. Although his work i s labe l l e d psychoanalytic, Redl's descriptions of s t a f f / c h i l d i nteraction cut across t h e o r e t i c a l boundaries and helps to uncover the basic elements of re s i d e n t i a l treatment. His approach has much in common with the common sense, experience-based approach that developed at Vanhouse p r i o r to the introduction of systemic/strategic methods. For t h i s reason, a thorough coverage of the Redl approach i s provided. The cornerstone of the Redl approach i s a view of childhood pathology as an indication of a poorly functioning ego (Redl, 1 9 5 2 ) . Ego i s that part of the personality which keeps us i n touch with r e a l i t y and with which we regulate our impulse expression so that i t i s within the bounds which such a r e a l i t y d i c t a t e s . Redl suggests that the c h i l d referred for treatment t y p i c a l l y i s unable to adequately deal with the numerous impulses which continually challenge the ego. For 2 1 example, such children are unable to handle fear, anxiety, or insecurity of any kind without breakdown into disorganized aggression (Redl & Wineman, 1 9 5 1 ) . The aggression leads to g u i l t and since the c h i l d ' s ego i s weak and unable to deal with the g u i l t , a cycle begins where g u i l t leads to aggression, aggression leads to g u i l t , etc. In Redl's extensive work with children, i t became clear to him that the "individual treatment process", seeing the c h i l d once or twice a week for an hour at a time, was r e l a t i v e l y i n e f f e c t u a l compared to what might be provided in a treatment home. Also, and most importantly, he r e a l i z e d that the treatment provided by the home should be on-going and as such be primarily provided by the c h i l d care s t a f f who have day-to-day contact with the children. In t h i s respect, as well as many others, Redl was well before his time, bringing the treatment to i t s grass roots level and thereby providing the children with a powerful environment for change. Redl describes the weakness of the individual treatment process in his c h a r a c t e r i s t i c a l l y f l a v o r f u l prose; No matter what geniuses we may be and what flawless job we may have performed in the treatment of a c h i l d ' s anxiety neurosis in our sessions, how can we get any place i f the same c h i l d spends 2 3 of the 2 4 hours of his waking and sleeping day in a framework which i s so f u l l of traumatic situations? How can we help a c h i l d i f soon aft e r his meeting with us, he steps into a world regimented by the compulsive picayunishness of suppressive roles and routines narrowed by a programless exposure to boredom, sprinkled with the over-stimulations coming from selec t i v e contagion-initiators i n his group, peppered with the scenes of s a d i s t i c punishment and sentimental teacher pet c u l t i v a t i o n , and punctured by nothing but wordy speeches and lectures from c h i l d -d isinterested representatives of so c i e t a l demands? ( 1 9 5 2 , p . 4 0 ) Faced with the inadequacy of the individual approach and the severity of the so c a l l e d "ego impairment" of the children in need of treatment, Redl developed a treatment process which included the t o t a l environment of the youngster. This " t o t a l environment" provided by Redl has as i t s basic goal the strengthening of the ego through various ego-supportive strategies. Redl ( 1 9 5 2 ) c l a s s i f i e s four basic modes of ego support; 1 ) the ego support by the impact of the design of the t o t a l environment, i . e . physical lay out, p o l i c i e s , rules, 2 ) the ego-supportive role of a c t i v i t y and program structures, 3 ) the techniques to handle day-to-day behavior, or what Redl c a l l s "surface behavior", and 4 ) the ego-supportive impact of the whole strategy of handling t h e i r own l i f e experiences. With ego support and strengthening as a basic treatment goal, Redl began to formulate his " t o t a l treatment design". The actual pioneering attempt to create a r e s i d e n t i a l treatment milieu had been made e a r l i e r by August Aichorn and i s described in his book "Wayward Youth" (Aichorn, 1935). However, for our purposes, Redl's approach offers a more in-depth account of the milieu approach. His t o t a l treatment approach requires that every aspect of the design be considered for i t s contributory therapeutic impact. This means that the physical layout of the home, the housekeeping p o l i c i e s , the r e l a t i o n s h i p between s t a f f members, and a l l the way down to the p a r t i c u l a r way meals are served, i s taken into account for i t s therapeutic influence. A key element of the Redl approach i s providing the children with a program that s a t i s f i e s t h e i r needs to have "fun". In other words structured a c t i v i t i e s , games and c r a f t s are not seen simply as t i m e - f i l l i n g programming but as an integral part of the therapeutic process. The s t a f f communicates through t h e i r encouragement and complete acceptance of the children's "fun a c t i v i t i e s " that they care about them and are there to support them in t h e i r need g r a t i f i c a t i o n . Staff are directed at a l l costs to avoid any messages of h o s t i l i t y towards the children's "fun a c t i v i t i e s " . When interference must be used, i t i s the " r e a l i t y l i m i t a t i o n s " attitude that must be conveyed. 24 It i s important to note at t h i s point that the c l i e n t s that Redl developed his treatment philosophy for were boys between the ages of 9 and 12 and therefore the structures and programming of the home i s tailor-made for that population. However, t h i s does not i n any way mean that Redl's ideas and techniques cannot be modified so as to be e f f e c t i v e with another population of children. This brings us to a most c r u c i a l area of treatment philosophy; the relat i o n s h i p between s t a f f and children. Just as the rel a t i o n s h i p between c l i e n t and therapist i n the individual or family counselling setting i s a l i v e l y and controversial issue, so i t should be within the r e s i d e n t i a l treatment context. However the l i t e r a t u r e on r e s i d e n t i a l treatment and relat i o n s h i p i s remarkably scarce when you consider how important t h i s issue i s to the overall treatment design. Most of the l i t e r a t u r e from the d i f f e r e n t approaches seems to suggest that a nurturing, supportive relationship i s a key ingredient of therapeutic success (Bettelheim, 1974; Jones, 1980; Brendtro & Ness, 1983), but few go on to describe that relationship or o f f e r a rationale to explain i t s therapeutic e f f e c t . This issue w i l l be described in d e t a i l at a l a t e r time, for now l e t us return to Redl and his thoughts on s t a f f -c h i l d r e l a t i o n s h i p . 25 Redl emphasizes that an accepting, affectionate relationship between s t a f f and children i s e s s e n t i a l , but stresses that the s t a f f must also play the role of "protector". The adult plays the role of protector in four s i g n i f i c a n t areas; protecting the c h i l d from other children, from himself, from outside interference and from p o t e n t i a l l y dangerous si t u a t i o n s . Interference to protect a c h i l d from his peers i s used sparingly and only in those situations where aggressive behavior reaches a p o t e n t i a l l y harmful l e v e l . Otherwise the children are l e f t to themselves to s e t t l e inter-group tension and c o n f l i c t . This non-interference strategy i s in agreement with the systemic approach to i n t e r a c t i o n a l problem resolution which w i l l be discussed in a l a t e r section. Protecting the children from themselves i s an important issue in treatment that, as we s h a l l see l a t e r , becomes a central concern i n the Vanhouse treatment philosophy. Children in treatment, even those with what Redl c a l l s weak-ego development, are acutely aware of when t h e i r behavior crosses the boundary into the inappropriate region. Redl believes that i f the s t a f f , for whatever reason, f a i l to provide l i m i t s to curb t h i s extreme behavior the c h i l d w i l l react i n a somewhat paradoxical manner by escalating the inappropriate behavior as an i n v i t a t i o n for more control by the s t a f f (Redl, 1952). In other words, the c h i l d i n seeking to f i n d the l i m i t s of his or 26 her power w i l l progressively escalate t h e i r behavior u n t i l e f f e c t i v e l i m i t s are placed upon them. This dynamic i s sometimes referred to as "testing" by c h i l d care workers and the new s t a f f member i s constantly "tested" i n a methodical and persistent manner by the probing children. Once the c h i l d f e e l s confident that a p a r t i c u l a r s t a f f member w i l l consistently provide protective l i m i t s , the probes, v i a inappropriate behavior, subside and the c h i l d appears to relax and displays more c o n f l i c t - f r e e behavior. Redl (1952) notes that not only does the c h i l d become more aggressive when protective l i m i t s are not established but he/she w i l l react negatively afterwards to that p a r t i c u l a r s t a f f who missed t h e i r function of protective interference. Some of these "protective functions" described by Redl (1952) are what most people commonly refer to as d i s c i p l i n e and they take a central role i n Redl's treatment approach. Whenever Redl's s t a f f interferes with a c h i l d ' s behavior they are cautious to frame the interference as protective and caring, as opposed to punishing which i s associated with disapproval. This attitude towards inappropriate behavior i s what Redl (1952) believes c l e a r l y distinguishes his treatment approach from educational programs. Educational programs commonly reward p o s i t i v e behavior and r e s t r i c t or punish behavior which i s seen as inappropriate or undesirable 2 7 (Brendtro & Ness, 1 9 8 3 ) . In Redl's approach undesirable symptoms are tolerated with an attitude of acceptance, coupled with an expectation for eventual change. The message which Redl suggests should i d e a l l y be transmitted to the children can be summarized: "We l i k e you, we take you the way you are, but of course i n the long run we'd l i k e you to change". (Redl, 1 9 5 2 , p. 5 9 ) There i s a f i n e l i n e between "permissiveness" on the one hand and "symptom tolerance" on the other. The attitude of tolerance allows the symptoms to come out i n the open, to be exposed, so that they can be manipulated and used for treatment purposes. A permissive attitude, on the other hand, lends i t s e l f to misinterpretation as the c h i l d might assume that the s t a f f has taken a position of indifference to the inappropriate behavior or i s a c t u a l l y encouraging the c h i l d to act out. The creation of an appropriately tolerant atmosphere i s a serious strategic issue, one which creates much controversy and discussion i n any r e s i d e n t i a l treatment s e t t i n g . We can view l i m i t setting, or what Redl ( 1 9 5 2 , p. 5 7 ) c a l l s " l i m i t interference", as one type of interaction which occurs between s t a f f and children during treatment. Another int e r a c t i o n , of a more po s i t i v e kind, i s the display of a f f e c t i o n and warmth. Redl believes that a heavy dose of 2 8 a f f e c t i o n i s required to carry out e f f e c t i v e treatment and that t h i s a f f e c t i o n should be d i s t r i b u t e d evenly amongst the group. It appears that the ideal relationship between st a f f and c h i l d that Redl envisions i s very similar to Carl Rogers' ideal r e l a t i o n s h i p between therapist and c l i e n t (Rogers, 1 9 6 1 ) . Redl stresses that element of the r e l a t i o n s h i p which Rogers c a l l s "unconditional p o s i t i v e regard", using the term "tax-free" love instead (Redl, 1 9 5 2 , p . 6 1 ) . The following quote summarizes Redl's po s i t i o n on the relationship between s t a f f and children; The children must get plenty of love and a f f e c t i o n whether they deserve i t or not; they must be assured the basic quota of happy recreational experiences whether they seem to have i t coming or not. In short love and a f f e c t i o n , as well as the granting of g r a t i f y i n g l i f e situations, cannot be made the bargaining tools of educational or even therapeutic motivation, but must be kept tax-free as minimum parts of the youngster's d i e t , i r r e s p e c t i v e of the problems of deservedness. (Redl, 1 9 5 2 , p . 6 1 ) One of the most valuable contributions provided by Redl i s his detailed descriptions of s p e c i f i c techniques for handling problem behavior. Redl refers to these techniques as "the a n t i s e p t i c manipulation of surface behavior" (Redl, 1 9 5 2 , 2 9 p.153). Many of the 17 techniques described by Redl are used by c h i l d care workers, as well as parents, on a "common sense" or "common knowledge" basis. Redl goes one step further and provides t h e o r e t i c a l support for these interventions and suggests when and how to most e f f e c t i v e l y apply them. The "antiseptic" that Redl refers to suggests that, whatever the goal of the intervention, the c l i n i c i a n or front l i n e worker must f i r s t be concerned that the intervention i s not counter-therapeutic. In other words, although there i s a d e f i n i t e requirement for the s t a f f to provide l i m i t s i t must be ca r r i e d out i n such a manner than any therapeutic gains that have been made thus f a r are not destroyed. The loss of established rapport between s t a f f and c h i l d and the creation of a traumatic episode are two examples of the p o t e n t i a l l y counter-therapeutic e f f e c t s of s t a f f interventions. Due to the constraints of space a thorough coverage of Redl's various interventions w i l l not be undertaken. However since Redl's work of f e r s the only in-depth analysis of the day-to-day interactions between s t a f f and children and since these interventions are often considered the core component of any re s i d e n t i a l treatment approach, a description of some of the key interventions follows. 3 0 Interventions are not simply techniques to provide a safe and manageable environment, they are also important ingredients in the therapeutic process. One of the most interesting and deceivingly simple techniques i s c a l l e d "planned ignoring" (Redl, 1 9 5 2 , p. 1 5 8 ) . Planned ignoring e s s e n t i a l l y means that the s t a f f member avoids i n t e r f e r i n g i n behavior that may on the surface appear inappropriate. Child care workers with considerable experience become very adept at s i z i n g up a s i t u a t i o n quickly and deciding i f t h e i r inteference w i l l help to solve the s i t u a t i o n or simply exacerbate i t . The d i f f i c u l t part, of course, i s to know when to l e t something go and when to i n t e r f e r e . A t y p i c a l example might be the case where a frustrated teenager returns from a d i f f i c u l t day at school and comes stomping in the house glaring at anyone who crosses his/her path. Depending on a number of factors, such as; who the c h i l d i s , who else i s in the house and the rapport developed between s t a f f and c h i l d , the s t a f f member may decide to ignore the behavior or, on the other hand, the s t a f f may decide to intervene immediately. By ignoring the behavior the s t a f f avoids becoming part of the problem. This technique of planned ignoring has a similar rationale to the problem resolution proposed by Watzlawick et a l . in t h e i r book, "Change" (Watzlawick, Weakland & Fisch, 1 9 7 4 ) . Watzlawick refers to f a u l t y interference as "when the solution becomes the problem" (Watzlawick et a l . , 1 9 7 4 , p. 3 1 ) . 31 Another intervention of s i g n i f i c a n t interest i s what Redl refers to as "interpretation as interference" (Redl, 1952, p.178). Redl describes i t as the attempt to help a c h i l d understand the meaning of a situ a t i o n which he has misinterpreted, or to help him grasp his own motivation i n an issue at hand. The on-going treatment provided by the Redl approach requires the s t a f f member to intervene through "interviewing" the c h i l d whenever a s i g n i f i c a n t incident occurs. Redl c l a s s i f i e s six types of interviews under the following categories; "the rub-in interview", "guilt-squeeze interview", "expressional interview", "interpretation interview", "counter-distortional interview" and the "group interview" (Redl, 1952, p. 254). These interviews function to defuse disruptive behavior and therapeutically act as a means to support and strengthen the ch i l d ' s weak ego. Each of these interviewing styles are f a m i l i a r to c h i l d care workers and other professionals working with children who have had considerable experience in the f i e l d . In summary, we can see that one of the most unique aspects of the Redl approach i s the use of the t o t a l treatment design to influence behavioral change. The treatment environment i s viewed as a shaping tool which can be manipulated either to "soften or lure out symptomatic behavior" (Redl, 1952, p. 307). Treatment takes place i n an on-going fashion with the display of pathological behavior seen as an opportunity for the s t a f f to provide an appropriate treatment intervention. Redl's "techniques for the manipulation of surface behavior" provides us with a good description and rationale for many of the interventions which c h i l d care workers use both i n the psychoanalytic t r a d i t i o n and many of the other treatment approaches. Redl's micro-analysis of the da i l y i n t e r a c t i o n between s t a f f and c h i l d suggests the paramount importance of the re l a t i o n s h i p between these two pa r t i e s . It i s important to note at t h i s point that the psychoanalytic label associated with Redl's work i s perhaps somewhat of a misnomer. Redl's work i s psychoanalytic in the sense that he uses psychoanalytic terms to describe the maladaptive behavior displayed by children in care. However his interventions are not " t r a d i t i o n a l l y psychoanalytic" and as such they stand on t h e i r own, independent of any label or school of psychology. BEHAVIORAL RESIDENTIAL TREATMENT The introduction of behavioral concepts and techniques to the milieu approach came at a much la t e r date than those of the psychoanalytic t r a d i t i o n . Like Redl the behaviorists believed that to have a s i g n i f i c a n t treatment impact the therapy should 3 3 be provided i n an on-going manner, not by a psychotherapist who i s both p h y s i c a l l y and e x p e r i e n t i a l l y removed from the c h i l d ' s natural l i f e milieu (Whittaker, 1979). In the early 1960's a group of psychologists and educators at the University of Washington f i r s t attempted to apply the p r i n c i p l e s of behavior analysis i n a natural setting. These i n i t i a l studies examined the e f f e c t s of teacher attention in maintaining problem behavior i n children. In a series of experiments, the investigators demonstrated that such diverse behaviors as a regressed crawling (Harris et a l . , 1964), s o c i a l l y i s o l a t e behavior (Allen et a l . , 1964), excessive crying and whining (Hart et a l . , 1964), and excessive scratching (Allen & Harris, 1966) were d i r e c t l y controlled by t h e i r immediate consequences in the environment - i n t h i s case the attention of adults. By s e l e c t i v e l y withholding and dispensing s o c i a l reinforcement the experimenters were successful at a l t e r i n g the above behaviors. Encouraged by t h i s success, a number of school programs, treatment centers, and group homes adopted behavior modification programs. Whittaker (1979) points out that although individual behaviorists d i f f e r e d i n s t y l e and emphasis t h e i r e f f o r t s were founded on the following agreed-upon p r i n c i p l e s : 1) A c h i l d ' s psychological nature i s his behavior; d i r e c t l y observable and measurable actions constitute the sum and substance of personality. The behaviorist rejects the notion of inner 3 4 personality - states such as i d , ego and super ego. 2 ) Behavior i s largely controlled by the environment and, i n the case of operant or active behavior, i s either strengthened, maintained, or diminished by i t s immediate ef f e c t s on the environment. Therefore i f the reinforcers for any given behavior can be i d e n t i f i e d and brought under control, the behavior i t s e l f can be s i m i l a r l y controlled. 3 ) The symptom of the troubled c h i l d i s the entire problem; i t i s not simply an external manifestation of some underlying disease process, psychoneuurosis or character disorder. If the acting • out of the delinquent, or the bizarre behavior of the psychotic c h i l d , i s stopped, then the basic problem of delinquency or psychosis has been solved (taken from Whittaker, 1 9 7 9 , p. 5 7 - 5 8 ) . From a p r a c t i c a l standpoint behavior treatment i s i n v i t i n g i n that there i s no need to analyze the so-called "deep seated" contributors to an individual's current pathological behavior. The behaviorist simply takes the problem behaviors as they stand and looks for clues to how these behaviors are e l i c i t e d -and maintained within the ch i l d ' s environment. As Whittaker ( 1 9 7 9 ) points out, treatment usually involves four stages; 1 ) i d e n t i f y i n g and specifying the problem behavior, 2 ) determining the c o n t r o l l i n g conditions; patterns of reinforcement, learning history, environmental factors, 3 ) specifying the pro-social behavioral goals, 4 ) applying any number of behavioral techniques, either singly or in combination, followed by a precise evaluation of progress. 3 5 A t y p i c a l example of behavior modification in a r e s i d e n t i a l setting involves the use of a "point system" which i s monitored d a i l y . A number of behaviors are i d e n t i f i e d which are considered either desirable or undesirable and a reward system i s established contingent on these behaviors. At the end of the day, the accumulated points are tabulated and some reward such as money or extra p r i v i l e g e s i s given to the c h i l d . In some programs there i s the contingent use of both p o s i t i v e and negative reinforces to simultaneously accelerate desired behaviors and decelerate undesirable ones. One of the most noteworthy behavioral milieu treatment programs for disturbed children was described by P h i l l i p s i n the early 70's ( P h i l l i p s et a l . , 1973a). The goal of the program, c a l l e d Achievement Place, was to teach youths the basic s k i l l s to help them avoid problems with t h e i r f a m i l i e s , teachers and the law. The youths selected for the program l i v e d with a professionally trained couple, "teaching parents", who interacted c l o s e l y with the youth and cl o s e l y monitored t h e i r progress i n school, on home v i s i t s , and within the treatment environment. The youth i n Achievement Place progressed through a series of behavioral programs which gradually allowed them more p r i v i l e g e s and freedom as behavior improved. An interesting finding which i s especially relevant to t h i s thesis i s that an attempt to re p l i c a t e Achievement 3 6 Place i n another home proved to be a f a i l u r e . The explanation offered for t h i s f a i l u r e i s a lack of so c i a l reinforcement i n the second home. Social reinforcement apparently occurs when an intimate rel a t i o n s h i p develops between s t a f f and youth i n the process of dispensing points as reward. Without the development of t h i s kind of relat i o n s h i p the reward system f a i l s to encourage progressive change in the youth. P h i l l i p s reports that the point system could work at peak effectiveness only i n the context of a warm, open and giving interaction; "Many c l i n i c a l colleagues have t o l d us a l l along that 'relationship' i s an essential component of any therapy. We are now convinced that they are r i g h t . " ( P h i l l i p s et a l . , 1973a, p. 107). This question of relationship and how i t contributes to change i s a central concern i n t h i s t h e s i s . Although i t i s c l e a r l y impossible to determine the r e l a t i v e treatment e f f e c t s of "relationship" between s t a f f and c h i l d as compared to the contribution provided by techniques, i t i s important to keep in mind that these two variables l i k e l y have an i n t e r a c t i v e e f f e c t . As mentioned above, even the behaviorists, who usually focus on reinforcement schedules and other behavioral techniques, concede that without a close interpersonal relati o n s h i p , successful treatment i s un l i k e l y . The behavioral approach to r e s i d e n t i a l treatment i s more standardized and systematic than most other treatment programs. The goals and techniques for treatment are often c l e a r l y l a i d out and as a resu l t the approach lends i t s e l f p a r t i c u l a r l y well to comprehensive evaluation. Problems that have been encountered include program design and s t a f f attitudes and reactions (Browning & Stover, 1 9 7 1 ) . It appears that d i f f i c u l t i e s a r i s e when one attempts to balance a program stressing equally the acceleration of desirable behavior and the deceleration of undesirable behavior, and at the same time offer continuous pos i t i v e reinforcement to e l i c i t increasingly complex behaviors. Staff often report that they f i n d behavior modification techniques "unnatural" and as a result t h e i r attitudes toward the program undermines i t s effectiveness (Whittaker, 1 9 7 9 ) . Browning and Stover ( 1 9 7 1 ) found li m i t a t i o n s to the generalization of ef f e c t s and i n providing a treatment environment that gradually approximated the home setting. Their conclusion was that one should not assume generalization but, rather, should work to ensure that what i s learned in one setting i s e l i c i t e d and maintained i n another. GUIDED GROUP INTERACTION The t h i r d major treatment approach to Group Interaction. This approach stresses discuss i s Guided the importance of 3 8 viewing the c h i l d as part of a s o c i a l system within the treatment i n s t i t u t i o n . As with both the psychoanalytic and behavioral approaches the guided group interaction proponents argue that treatment effectiveness i s highly dependent on the qual i t y of the day-to-day interactions the c h i l d has with those individuals who share his l i f e space. Most importantly, the guided group interaction proponents stress the overwhelming influence of the c h i l d ' s peer culture on his or her behavior (Glasser, 1 9 6 9 ; Rose, 1 9 7 2 ; Strain, 1 9 8 1 ) . To encourage s i g n i f i c a n t treatment gains, the guided group approach (G.G.I.), u t i l i z e s the powerful influence of the peer group, acknowledging i t as an integral part of the treatment process. Goffman's ( 1 9 6 2 ) c l a s s i c study of i n s t i t u t i o n a l l i f e acted as a catalyst for the G.G.I. approach with the description of how i n s t i t u t i o n a l structure and processes were often contradictory to the formally stated treatment objectives of the i n s t i t u t i o n . Another s o c i o l o g i s t , Howard Polsky, also published a study which raised serious concerns about the effectiveness of i n s t i t u t i o n a l treatment for delinquent youth. In Polsky's ( 1 9 6 2 ) study, he acted as a participant observer i n the cottage i n s t i t u t i o n of Hollymeade. This i n s t i t u t i o n ' s treatment depended primarily on almost d a i l y i n d i v i d u a l therapy, with p s y c h i a t r i c a l l y trained personnel, which took place in an o f f i c e setting p h y s i c a l l y removed from the culture 3 9 of the cottage. The cottages were supervised by "cottage parents" who were minimally trained and e f f e c t i v e l y removed from the c l i n i c a l decision-making process of the i n s t i t u t i o n . Polsky's results suggested that the most powerful influence on the adolescent's behavior was not the individual treatment sessions or the interaction with the cottage parents but was in fact the delinquent subculture t h r i v i n g within the i n s t i t u t i o n . He discovered that the cottage had i t s "leaders", "status seekers", "con-artists", " i s o l a t e s " , "bush boys" and "scapegoats", and that a power structure existed based on intimidation through physical coercion, toughness and a code of silence. Polsky explains the weakness of the i n s t i t u t i o n a l experience; In the family, the c h i l d i s not exposed to a father and a mother, but to t h e i r i n t e r a c t i o n , t h e i r "family culture". In the i n s t i t u t i o n , the youngster i s barred from extensive interaction with professional s t a f f culture, yet he i s expected to achieve the l a t t e r ' s goals. In the cottage, hard-pressed cottage parents are outnumbered by delinquent youths. Many boys improve i n spite of the negative peer pressure; others f a i l because of i t . (Polsky, 1 9 6 2 , 1 4 9 ) 4 0 The guided group proponents recognized t h i s overwhelming subcultural influence and decided to structure t h e i r treatment using the peer group as an integral part of the therapeutic endeavor. P i l n i c k ( 1 9 7 1 ) defines the approach as follows; Guided Group Interaction i s a process of group treatment which di r e c t s the dynamics and strengths of the peer group toward constructively a l t e r i n g and developing the behavior of the group members. Empey and Lumbeck ( 1 9 7 2 ) state that the basic objectives of G.G.I. are to question the u t i l i t y of persistent delinquency, to provide behavioral a l t e r n a t i v e s , and to provide recognition for a youth's personal reformation and for his willingness to help reform others. The guided group approach attempts to use the peer group to develop p o s i t i v e pro-social values and reinforces conformity by strongly sanctioning behavior that v i o l a t e s group norms (Whittaker, 1 9 7 9 ) . The group i t s e l f i s often given decision-making power to determine what p r i v i l e g e s and r e s p o n s i b i l i t i e s each of the members deserve. Members of the group are usually required to attend highly structured group sessions where each of the participants reports on how they are "handling the si t u a t i o n " and receives feedback from the other members. 4 1 Intense group dynamics are generated that must be monitored clos e l y by a s t a f f who acts as a group leader. T y p i c a l l y the group members deal with the following issues; low self-esteem, inconsiderate of others, authority problem, misleads others, e a s i l y misled, aggravates others, e a s i l y angered, stealing, alcohol or drug problems, lying and fronting (trying to be something you are not; clown, tough guy, dumb-bell) (Vorrath & B r e n d t r o , 1 9 7 4 ) . Honesty, of course, i s highly valued and confrontation i s i m p l i c i t l y encouraged by the group leader. Vorrath and Brendtro ( 1 9 7 4 ) described the group leader's primary verbal behavior as "questioning" and stimulating the group toward the solution of problems. The sessions follow a s t r i c t agenda; reporting problems, awarding the meeting, problem-solving and leader summary. Due to the p o t e n t i a l l y explosive atmosphere that can be expected when a group interacts at an intense l e v e l , the group leader must be s k i l l f u l and knowledgeable of group dynamics. Losing control of the group or misreading an individual's responses can have serious detrimental effects on group members. The question of the r e l a t i v e effectiveness of guided group approaches as compared to other programs remains unresolved. Stephenson and S c a r p i t t i ( 1 9 7 4 ) reviewed several i n s t i t u t i o n s and community based guided group programs and found that the 4 2 guided group graduates fared somewhat better than the t r a d i t i o n a l reformatory graduates, but not as well as youths on parole. A common c r i t i c i s m of the guided group approach i s that to a large extent i t seems to be based on personality rather than method (Whittaker, 1 9 7 9 ) . In other words, programs with a charismatic leader may be successful simply because the strong personality of the leader acts as an agent for change. Whittaker suggests, however, that for older adolescents whose delinquent behavior originates and i s maintained in the peer group, Guided Group Interaction presents a p o t e n t i a l l y powerful technique for going to the heart of the delinquent's subculture and orientating i t in a positi v e d i r e c t i o n . THE RE-ED APPROACH The fourth, and la s t treatment approach to be examined i s the Re-ed concept introduced by Hobbs ( 1 9 6 7 ) . The Re-ed program i s an American adaptation of the "educateur" role that was common i n Western Europe. Re-ed i s a combination of group l i v i n g and special education in small, community based programs. The acquis i t i o n of new l i f e s k i l l s and the enhancement of the chi l d ' s learning a b i l i t i e s are basic goals for t h i s approach. Staff usually have a background in classroom teaching and are trained i n life-space interventions. Re-ed's focus on education aims to stimulate the c h i l d i n his 4 3 environment and to re-activate his natural a b i l i t y to acquire new s k i l l s and knowledge (Brendtro & Ness, 1 9 8 3 ) . Hobbs ( 1 9 6 4 ) explains that the learning bias of the Re-ed approach i s based on an assumption that the c h i l d who i s experiencing problems needs to learn how to learn. The core components of the Re-education process are, according to Hobbs; developing t r u s t , gaining competence, nurturing f e e l i n g s , c o n t r o l l i n g symptoms, learning middle class values, attaining cognitive control, developing community t i e s , providing physical experience, and knowing joy. A c r i t i c i s m that may be l e v e l l e d against the Re-ed program i s that although i t s proponents are strong on accenting the natural strengths of children and present an optimistic scenario, they f a i l to provide concrete information on how to deal with problem behavior and how to "reach" the severely disturbed c h i l d . The teacher-counsellor, who appears to be the main stay of t h i s approach, i s described as "a decent adult; educated, well trained, ... a person of hope, quiet competence and joy". (Hobbs, 1 9 6 4 , p. 1 5 ) . Every treatment program would hope that t h e i r s t a f f meet t h i s description, but i s the exposure to "decent" adults a potent enough force to s i g n i f i c a n t l y a l t e r the entrenched behavior problems of children in care? Furthermore, although the Re-education process i s l i k e l y a p o s i t i v e agent for change, does one not 4 4 require the cooperation and willingness of the c h i l d to partake in educational experiences? In the development of the Re-ed program, the Re-ed schools have gravitated towards behavioral approaches to treatment. However, Hobbs in reviewing the f i r s t 20 years of project Re-ed states that the behavioral component of the program should not be over-emphasized. He states that behavioral modification "... pays i n s u f f i c i e n t attention to the evocative power of i d e n t i f i c a t i o n with an admired adult, to the rigorous demands of expectancy stated and i m p l i c i t in situations, and to the f u l f i l l m e n t that comes from the exercise of competency" (as c i t e d in Brendtro & Ness, 1983). With the de-emphasis of behavioral techniques, the problem s t i l l remains of how to motivate and l i m i t the behavior of troubled youth. In many respects, one questions whether Re-ed can be c l a s s i f i e d as a treatment approach as i t appears to belong more to the special education f i e l d . Nevertheless, Hobbs' philosophy has contributed to the general f i e l d of r e s i d e n t i a l treatment by stimulating discussion and drawing attention to community based treatment p o s s i b i l i t i e s . That completes the review of the t r a d i t i o n a l approaches to r e s i d e n t i a l treatment. Each of the above theories has i t s own" view of human nature and change. This view i f re f l e c t e d in the 4 5 strategies and structures that each treatment approach adopts in an e f f o r t to enhance therapeutic change. In the following section, the strategies suggested by the family therapy movement with t h e i r corresponding view of human nature and change w i l l be reviewed and contrasted with the t r a d i t i o n a l approaches outlined above. THE STRATEGIC/SYSTEMIC APPROACH In t h i s section, some of the strategies and theory related to the strategic/systemic approach* w i l l be reviewed, followed by a review of the l i t e r a t u r e which deals s p e c i f i c a l l y with the use of strategic/systemic methods in treatment settings. As was mentioned e a r l i e r , much of the l i t e r a t u r e on paradoxical psychotherapy originated and was used predominantly by family therapists working with the family as a unit. Working with the family as a unit requires that the therapist adopt an in t e r a c t i o n a l perspective; viewing each family member as part of a larger system which influences his or her behavior. Some paradoxical therapy has been used with i n d i v i d u a l s , both in a c l i n i c a l setting and within r e s i d e n t i a l , school or hospital settings. Weeks and L 'Abate ( 1 9 8 2 ) refer to three levels of paradoxical intervention; the i n d i v i d u a l , i n t e r a c t i o n a l and transactional or systemic. In the f i r s t 46 l e v e l , the paradoxical intervention i s directed toward only one person or one member of the family. The second l e v e l or int e r a c t i o n a l level involves the d i r e c t i o n of the intervention at a l l the members of the system, but as in d i v i d u a l s . This level provides interlocking paradoxical messages, which as Weeks and L'Abate (1982) point out, focus on dyadic interactions. The t h i r d level of intervention i s the transactional, where the paradoxical message i s directed at the entire system in an attempt to capture the dilemma that faces the family or group. This thesis i s primarily concerned with the use of individual paradoxical interventions with adolescents i n a r e s i d e n t i a l setting and therefore emphasis w i l l be placed on the f i r s t category i d e n t i f i e d by Weeks and L'Abate (1982). It i s important to note that paradoxical interventions directed at individuals may involve and refer to other people, but they are directed at only one person at a time. When formulating a paradoxical message that i s to be directed at an individual i t i s essential that one adopt an inte r a c t i o n a l perspective, taking into consideration other individuals that may be contributing to the maintenance of the problematic behavior (Watzlawick et a l . , 1974). 47 The d i s t i n c t i o n between f i r s t and second-order change provides a good introduction to the strategic/systemic view of change and problem resolution. Watzlawick et a l . (1974), discuss two levels of change based on the work of a cyb e r n e t i c i s t (Ashby, 1956), who coined the f i r s t and second-order change. First-order change refers to change within a given system. In t h i s level of change, the system remains intact while some elements within i t undergo a change i n quantity. First-order change involves applying old solutions to new problems. If a problem becomes evident that has been solved in the past with some solution, the solution i s applied again. If the problem f a i l s to be resolved then "more of the solution" i s applied in a linear or step-wise fashion (Weeks & L'Abate, 1982). A relevant example would be the progressive withdrawal of p r i v i l e g e s for a resident in a treatment home who continues to misbehave. More of the same, i n the form of punishment, i s used in an attempt to solve the problem. Second-order change i s a change of the system i t s e l f . The system i s said to move to a higher level of functioning and the body of rules which governs the group i s altered to f i t the new structure. Second-order change often appears unusual, unexpected or uncommon-sensical and there i s a paradoxical element to the process of change (Watzlawick et a l . , 1974). In reference to the f i r s t example, a second order change solution \ 4 8 might be to suggest to the misbehaving adolescent that for the time being he/she seems to need less structure (rules, etc.) because she/he can't seem to comply with the ones already established. This attempted solution i s q u a l i t a t i v e l y d i f f e r e n t from the f i r s t - o r d e r solution mentioned e a r l i e r . From a f i r s t - o r d e r change perspective t h i s attempted solution seems e n t i r e l y i l l o g i c a l ; how could less punishment ever begin to solve a problem of continuing misbehavior? Second-order change solutions focus on the previously attempted solution. As Watzlawick et a l . ( 1 9 7 4 ) points out, i t i s the attempted solution which i s often at the root of the problem. In many situations with adolescents, parents and c h i l d care workers attempt to solve a problem by applying more and more force even when t h i s attempted solution proves to be unsuccessful. After a while i t i s t h i s attempted solution, the application of force, which becomes the problem. Watzlawick et a l . ( 1 9 7 4 ) describe three ways i n which problems can be mishandled: a) A solution i s attempted by denying that a problem e x i s t s . In other words, an action i s necessary but i t i s not taken. b) A change i s attempted regarding a d i f f i c u l t y which i s r e a l l y unchangeable or non-existent. For example, try i n g to stop somebody from f e e l i n g sad when they have a legitimate reason to f e e l that way - action i s taken when i t should not be. 4 9 c) First-order change solution i s repeatedly attempted when a second-order change solution i s required. This kind of attempted solution i s the same as the one mentioned above where more force i s added when an e n t i r e l y d i f f e r e n t strategy would be more e f f e c t i v e . This kind of error can also take place when a second-order change i s attempted when a f i r s t - o r d e r change would be appropriate. For example when a parent i n s i s t s that a c h i l d "want" to study instead of s e t t l i n g for an increase i n the amount of time a c h i l d spends studying (Watzlawick, 1 9 7 4 p. 3 9 ) . When problems are mishandled either i n the family or treatment home, a long-standing, c y c l i c a l pattern can be established that i s d i f f i c u l t to a l t e r . Paradoxical interventions are introduced to force the individual or system to adopt a second order solution to the problem. Weeks and L'Abate ( 1 9 8 2 ) have described three types of paradox: antimony, semantic antimony and the pragmatic paradox. It i s t h i s t h i r d type, the pragmatic paradox, that i s used as a basis for paradoxical psychotherapy. A good example of a pragmatic paradox i s the d i r e c t i v e "be spontaneous". As you can see t h i s sort of request i s impossible to carry out. The Palo Alto group i s credited for f i r s t using the pragmatic paradox i n a research setting and for attempting to uncover a theo r e t i c a l explanation for i t . Their c l a s s i c paper published i n 1 9 5 6 was e n t i t l e d "Toward a Theory of Schizophrenia" (Bateson et a l . , 1 9 5 6 ) . 5 0 The Palo Alto group suggested that schizophrenia could be produced through repeated exposure to a cert a i n kind of, what they c a l l e d , pathological communication. The term they used for t h i s communication was the double-bind. For double-bind communication to take place, a number of conditions must be met over a period of time. F i r s t of a l l , there must be communication, verbal or nonverbal, between two or more persons who are c l o s e l y connected (e.g. family members). The second requirement i s a recurrent theme of communication between the pa r t i e s . In other words, a single experience i s not considered s i g n i f i c a n t . Thirdly, a primary negative injunction must occur. This refers to a conditional type of communication l i k e "If you don't do so and so, I w i l l punish you" or "If you do so and so, I w i l l punish you". Most often the withdrawal of love or attention i s threatened as punishment for some behavior or lack of i t . The fourth condition c a r r i e s the double-bind and consists of a secondary message which c o n f l i c t s with the f i r s t . As Weeks and L'Abate (1982) describe i t , t h i s secondary message i s generally more d i f f i c u l t to i d e n t i f y because i t i s usually conveyed at a nonverbal l e v e l . The secondary message i s inconsistent with the f i r s t and puts the receiver of the communication in a no-win s i t u a t i o n . A common example of a secondary message i s crossing the arms and backing away while a primary message l i k e "I love you" i s simultaneously being communicated. The l a s t condition i s c a l l e d a " t e r t i a r y negative injunction" which disallows the victim to comment on the confusing message or to leave the f i e l d . The receiver or vi c t i m of t h i s kind of pathological communication i s l e f t "frozen", not knowing how best to respond to the contradictory messages. Also, as i s most often the case, the subtlety of the secondary nonverbal communication leaves the victim unaware of the confusing double-binding s i t u a t i o n they f i n d themselves i n . To "release" the victim from his no-win si t u a t i o n the Palo Alto group developed the therapeutic double-bind. In contrast to the pathogenic double-bind which places the person i n a no-win s i t u a t i o n , the therapeutic double-bind forces the c l i e n t into a no-lose s i t u a t i o n . A commonly used therapeutic double-bind i s the "prescription of the symptom". In t h i s case, the c l i e n t i s directed to continue displaying his symptoms and i s generally encouraged not to change. This binds the c l i e n t to accept one of two options, either a) continue the symptom, which implies control over a supposedly uncontrollable behavior, or b) discontinue the symptom, thereby going against the therapist's d i r e c t i v e and i n the process "curing" himself. Watzlawick et a l . (1967) explain the s i t u a t i o n , " i f he complies, he no longer 'can't help i t ' ; he does ' i t ' and t h i s , as we have t r i e d to show, makes ' i t ' impossible, which i s the purpose of therapy. If he r e s i s t s the injunction, he can do so 52 only by not behaving symptomatica1ly, which i s the purpose of therapy" (p. 241). It appears that part of what makes a pragmatic paradox or therapeutic double-bind work i s the message within the message. If a c l i e n t i s t o l d to continue behaving symptomatically the secondary message i s "You are i n control of your behavior". Once the c l i e n t i m p l i c i t l y receives the message i t makes i t d i f f i c u l t to display the problem behavior. Although the Palo Alto group were the f i r s t to research the pragmatic paradox, Al f r e d Adler i s credited with f i r s t using and writing about i t (Mozdzierz et a l . , 1976). According to Mozdzierz, Adler used paradoxical techniques to avoid power struggles with his c l i e n t s . By encouraging the c l i e n t to display the problem behavior, Adler side-stepped the issue of resistance between c l i e n t and therapist. Mozdzierz describes some of the paradoxical strategies employed by Adler; 1) Permission - giving the c l i e n t permission to have the symptom; 2) Prediction - predicting the c l i e n t ' s symptoms would return; 3 ) Proportionality - getting the c l i e n t to exaggerate symptoms or have the therapist take them more seriously than the c l i e n t ; 4) Pro-social r e d e f i n i t i o n - reframing or reinterpreting the symptomatic behavior i n a p o s i t i v e way; 5) P r e s c r i p t i o n -d i r e c t i n g the c l i e n t to behave in a symptomatic way; 6) 53 Practice - asking the c l i e n t to refine or improve his symptomatic behavior. Behavior therapists also use a technique which i s paradoxical i n nature. Implosive therapy uses the process of extinction to eliminate avoidance behavior. Phobic reactions and problems l i k e fear or r e j e c t i o n , sexual deviations, loss of impulse control and aggression have been treated using implosive techniques (Stampfl, 1967). The therapy requires the c l i e n t to use guided imagery, imagining scenes of some avoided behavior from least anxiety provoking to most anxiety provoking. The c l i e n t never actually p articipates in the phobic behavior but instead imagines i n d e t a i l the most threatening of sit u a t i o n s . Another th e o r i s t whose work has a paradoxical element to i t i s Victor Frankl. Frankl's logo therapy makes use of a powerful technique which he c a l l s paradoxical intention. According to Frankl (1975), he was using t h i s technique i n 1925 and documented i t s use i n a paper published i n 1939 (as c i t e d in Weeks & L'Abate, 1982). When using t h i s technique, the therapist d i r e c t s the c l i e n t to i n t e n t i o n a l l y w i l l the symptom to occur. Frankl encourages the adoption of a humorous attitude towards the symptom and hopes that the c l i e n t w i l l take a more detached, objective view of t h e i r s i t u a t i o n . 54 The goal of paradoxical intention i s to interrupt the vicious cycle of anticipatory anxiety which Frankl believes i s at the root of anxiety neurosis and phobic reactions. Anxiety occurs when the patient imagines a feared stimulus, thus leading to an avoidance reaction. By i n t e n t i o n a l l y w i l l i n g the symptom to appear the patient i s freed from the cycle of anxiety and avoidance. Rosen (1953) used a procedure c a l l e d "re-enacting an aspect of psychosis" to treat psychotic behavior. This procedure, which i s similar to prescribing the symptom, involved d i r e c t i n g the patient to re-enact any bizarre behavior that they had exhibited. Rosen provides a rationale for the procedure; Whenever your hunch t e l l s you they are i n danger of repeating some such i r r a t i o n a l i t y , you beat them to the draw by demanding that they re-enact just exactly the piece of psychotic behavior that you fear they may f a l l into again. Perhaps your boldness indicates to the patient that you are w i l l i n g to take a chance of making him act crazy because you are convinced that he no longer can. Perhaps i t has something to do with the patient's sense of shame when you ask him to do something f o o l i s h and remind him that he used 5 5 to do t h i s f o o l i s h thing. Sometimes the patient makes an attempt to re-enact the symptom which comes out very feebly, obviously not spontaneous, and sometimes he w i l l say 'he did i t to humor you'. When the patient has c l e a r l y l o s t his touch, the therapist has reason to r e j o i c e . (cited i n Weeks & L'Abate, 1 9 8 2 , p. 1 1 ) In his use of paradoxical techniques with psychotic patients, Rosen ( 1 9 5 3 ) claims to have achieved remarkable success. One of his studies reports that 3 6 out of 3 7 schizophrenics recovered to the extent of achieving the emotional s t a b i l i t y of normal in d i v i d u a l s . Rosen's work i s highly creative and provides a good example of how paradoxical psychotherapy can be used with even the most severe psychological problems. Gestalt therapy c l e a r l y seems to have a paradoxical element to i t . Beisser ( 1 9 7 0 ) suggests that Gestalt therapy i s based on a paradoxical theory of change. According to him, "change occurs when one becomes what he i s , not when he t r i e s to become what he i s not" (p. 7 7 ) . A technique known as "exaggeration" requires the c l i e n t to repeat behavior i n amplified movements or gestures, with the goal being to uncover the hidden meaning of the behavior. This emphasis on achieving 56 awareness of where one " i s " before being able to move on and change behavior i s also similar to client-centered Rogerian therapy. In client-centered therapy, the c l i e n t i s encouraged to accept himself in the present so as to move forward i n a process of s e l f - a c t u a l i z a t i o n (Rogers, 1961). Both the Gestalt therapist and the client-centered therapist assume the paradoxical role of not being a changer. Research by the Milan group (Palazzoli et a l . , 1978) had a di r e c t influence on the adoption of paradoxical techniques at the Vancouver House treatment home. Their work which, in turn, was inspired by Watzlawick (1967) i s based on a systemic orientation and focuses on the communication and behavioral transactions that occur within the family unit. According to the Milan group, a l l groups, including the family, have rules that govern the behavior of the unit. These rules, many of which are hidden or unarticulated, provide l i m i t s to what i s permitted and not permitted in the relationships amongst the group members. Pathological behavior within the family i s also governed by these "meta-rules" and the rules are r i g i d l y enforced to maintain the system's status quo. In t h e i r book "Paradox and Counterparadox" (1978), the Milan group states that when they are able to discover and change one fundamental rule, pathological behavior quickly disappears. 5 7 In order to f u l l y comprehend the work of the Milan group, one must be able to appreciate the systemic orientation to behavioral change. Many of the theories of human nature, psychoanalysis included, are based on a causal-mechanistic view of phenomena. The causal-mechanistic view suggests that present behavior i s determined by previous events i n a cause-and-effect manner. Pa l a z z o l i et a l . , ( 1 9 7 8 ) explained the importance of viewing the family systemically; ... we must abandon the causal-mechanistic view of phenomena, which has dominated the sciences u n t i l recent times, and adopt a systemic orientation. With t h i s new orientation, the therapist should be able to see the members of the family as elements in a c i r c u i t of i n t e r a c t i o n . None of the members of the family inevitably influences the behavior of the others. This i s because every member influences the others, but i s in turn influenced by them. The individual acts upon the system, but i s at the same time influenced by the communications he receives from i t . (p.5 ) Within the family unit, with each being influenced by the whole, surfaces whose behavior threatens the homeostatic member influencing and the i d e n t i f i e d patient tendency of the group. 5 8 The i d e n t i f i e d patient in acting in a bizarre, disruptive or withdrawn manner i s reacting, in the best way he knows how, to the c o n f l i c t i n g double-binding messages he receives from the rest of the family unit. Paradoxically, the disturbing behavior of the i d e n t i f i e d patient which has brought the family into therapy, threatens the s t a b i l i t y of the unit and at the same time permits the status quo to continue. The family i s said to be i n "schizophrenic transaction", hanging on desperately to the family rules which prohibit any change in the relationships amongst family members, and producing, in turn, the i d e n t i f i e d patient who functions to protect the s t a b i l i t y and cohesion of the group (Palazzoli et a l . , 1 9 7 8 ) . Recognizing t h i s powerful tendency to protect the status quo, the Milan group devised strategies to counter the family's homeostatic maneuvers. The most s i g n i f i c a n t general strategy i s c a l l e d "positive connotation" (Palazzoli et a l . , 1 9 7 8 ) . Facing the problem of attempting to change a system where each of the members covertly r e s i s t change and believe that "someone else needs to change", the Milan group decided t h e i r most e f f e c t i v e strategy would be to p o s i t i v e l y connote the behavior of each and every member of the family. By doing so they believe they "gain access to the systemic model" ( 1 9 7 8 , p. 5 6 ) , and underline and confirm the family's homeostatic tendencies. To provide a rationale for supporting the family members' 59 behaviors the therapist suggests that each of them i s doing t h e i r best to provide the family with s t a b i l i t y and cohesion. P o s i t i v e l y connoting the symptoms of the i d e n t i f i e d patient and the behavior of the other family members e x p l i c i t l y suggests that the family should remain the same and i m p l i c i t l y suggests that they should change. For as the Milan group states (1978, p. 61); "... p o s i t i v e connotation i m p l i c i t l y puts the family i n a paradox; why does such a good thing as the cohesion of the group require the presence of a 'patient'?" Now that a general review of the strategic/systemic l i t e r a t u r e has been presented, the focus w i l l be narrowed to examine strategic/systemic methods and ideas as they s p e c i f i c a l l y relate to the r e s i d e n t i a l treatment context. In order to do t h i s , the few studies that have been reported on the use of paradoxical methods in r e s i d e n t i a l setting w i l l be reviewed, followed by a review of the strategic/systemic l i t e r a t u r e as i t s p e c i f i c a l l y relates to s i g n i f i c a n t concepts within the r e s i d e n t i a l treatment context. The f i r s t paper describing the strategic use of paradoxical procedures on an in-patient c h i l d unit was written by Jessee and L'Abate (1980). As was mentioned e a r l i e r , these authors believe that paradoxical procedures can be very 6 0 e f f e c t i v e with children because the interventions require limited verbal a b i l i t y and insight, are normally short-term, can include an int e r a c t i o n a l perspective, and have proved to work well with oppositional i n d i v i d u a l s . The authors present us with three case examples and contraindications for t h i s type of intervention are discussed. In the f i r s t example provided, an 11 year old boy had been hospitalized for repeatedly stealing toys. The boy's mother reported a long history of depression and said that she handled a l l matters concerning the boy except for stealing which was dealt with by both the mother and the father. The father, who worked odd hours and had l i t t l e contact with the boy, would then dole out some d i s c i p l i n e . The s t a f f noticed that the boy had d i f f i c u l t y establishing relationships with the male s t a f f in the hospital but got along e a s i l y with females-. The intervention used was as follows: the s t a f f got together and t o l d the boy that they now understood how d i f f i c u l t i t was for him to l e t them know that he wanted to spend more time with the s t a f f . He was then t o l d that whenever he wanted to spend some enjoyable time with the male s t a f f he was to "take" (his word for stealing) a magazine from the counter. The s t a f f also t o l d the boy that when he "took" the magazine, the s t a f f , male and female, would get together and tal k about the s i t u a t i o n . The boy was congratulated for creating an opportunity for s t a f f to get together and share some information. 61 The boy's reaction to the d i r e c t i v e was astonishment and confusion, followed by anger and refusal to do the task even though he had previously agreed to i t . The authors report that the boy never followed through on the task and never stole again e i t h e r . In analyzing the intervention, we can see that the symptom, stealing, was p o s i t i v e l y connoted and given a pro-so c i a l rationale - getting the s t a f f together. Also, we can see that the d i r e c t i v e prescribes the symptom and provides an explanation for i t s function which p a r a l l e l s the hypothesized function i t has within the family system. The authors report that the following week the father and the boy spent an afternoon together, something they had not done in years. In addition, the mother reported f e e l i n g better than she had in weeks and exhibited a much brighter a f f e c t . These reports would suggest that the intervention had systemic repercussions, changing established patterns of interactions and upsetting the family homeostasis. In the second case study, a boy who had a long history of argumentative, oppositional behavior had these presenting problems prescribed. It was hypothesized that the disruptive behavior of the boy functioned to d i s t r a c t the parents from t h e i r own d i f f i c u l t i e s with each other. The boy was t o l d that his arguing with a female nurse was a good thing because i t helped her come out of her depression. He was t o l d to 62 misbehave in front of her whenever he f e l t she was depressed. The authors report that t h i s p r e s c r i p t i o n was used in the hopes of enabling the boy to get an experiential understanding of the function of his behavior i n the family. As with the f i r s t example, the boy refused to follow through with the pr e s c r i p t i o n and responded with blatant anger to the d i r e c t i v e . In the t h i r d case study, an 11 year old boy was admitted to hospital a f t e r the accidental shooting death of his younger brother. Apparently the boy had a long history of dangerous and destructive play and was very accident prone. The authors prescribed that the boy should have two accidents a day, using the rationale that i f they are going to happen, then he might as well learn to control them. They report that within three days the boy stopped having any accidents. Another intervention reported by Jessee and L'Abate (1980) provides the c h i l d with an explanation for his behavior and p o s i t i v e l y connotes i t . They report that t h i s procedure can be used i n a general way and has been found e f f e c t i v e with various behavioral d i f f i c u l t i e s . For instance, the c h i l d who i s having d i f f i c u l t y s e t t l i n g at night can be t o l d that his staying up i s an i n d i c a t i o n that he loves his parents very much and his parents would be proud of him for demonstrating his caring so convincingly. He i s then encouraged to stay up u n t i l he f e e l s 6 3 l i k e he has shown enough caring for his parents. The behavior, then, becomes framed i n such a way that staying up reassures the c h i l d that he i s cared for by his parents, labels the distr e s s as a pos i t i v e expression, and prescribes the symptom in a way that removes the need for i t . It i s inter e s t i n g to note that in the above case examples the symptomatic behavior that was presenting i t s e l f within the family environment was also displayed in the hospital s e t t i n g . Jessee and L'Abate's (1980) interventions seek to capture the int e r a c t i o n a l dynamics that are occurring in the hospital setting which p a r a l l e l the dynamics which are happening in the home set t i n g . Although the actors are d i f f e r e n t from one setting to the other, the intervention i s aimed at the same symptomatic behavior. One has to wonder, however, how often the case w i l l be so clear cut with the i d e n t i f i e d patient displaying the same symptom in the hospital setting as he displays at home with his parents. Jessee and L'Abate (1980) suggest that paradoxical interventions may be most successful with defiant children, e s p e c i a l l y those who r e s i s t being supported or helped i n any way. They also suggest that with highly compliant children, compliance-based paradoxical interventions can be quite e f f e c t i v e . With compliance-based paradoxical prescriptions the 6 4 assumption i s that the symptom w i l l cease when the patient attempts to w i l l f u l l y bring on the symptom. Compliance-based prescriptions seem to be es p e c i a l l y e f f e c t i v e with somatic complaints, depressions and phobias. Jessee and L'Abate's (1980) report that paradoxical interventions should not be used when children are i n intense c r i s i s , are experiencing disorganized thinking or are retarded. F i n a l l y , the interventions should always be framed within the r e a l i t y of the c h i l d , using concepts and language that are comprehensive to him/her. In "Positive Reframing With Children: Conceptual & C l i n i c a l Considerations"" (Jessee at a l . , 1982), the authors present us with the the o r e t i c a l and pragmatic aspects of pos i t i v e reframing with hospitalized middle-school aged children. The authors of t h i s a r t i c l e c r e d i t Watzlawick et a l . (1974) for introducing p o s i t i v e reframing as an active agent of change. According to Watzlawick et a l . (1974) reframing a l t e r s ; ... the conceptual and/or emotional setting or view point i n r e l a t i o n to which a si t u a t i o n i s experienced and places i t in another frame which f i t s the 'facts' of the same concrete s i t u a t i o n e s p e c i a l l y well or 6 5 even b e t t e r , and thereby changes i t s meaning. (p. 9 5 ) Jessee et a l . ( 1 9 8 2 ) r e p o r t t h a t p o s i t i v e reframing, amongst other t h i n g s , serves t o c o u n t e r a c t the negative e f f e c t s of p s y c h i a t r i c l a b e l l i n g . Once the c h i l d ' s behavior has been p o s i t i v e l y reframed, he/she can no longer be seen i n a s t r i c t l y n e g a t i v e l i g h t . A new more p o s i t i v e view of the c h i l d behavior can a f f e c t the group processes and a l t e r e s t a b l i s h e d f a m i l y behavior p a t t e r n as w e l l as b o o s t i n g the c h i l d ' s s e l f - e s t e e m and encouraging progress i n h i s or her i n t r a p e r s o n a l m a t u r a t i o n a l development. As the authors s t a t e , p o s i t i v e reframing ... may serve as a p o s i t i v e stimulus t o the c h i l d ' s d e v e l o p i n g a b i l i t y to c o n s i d e r simultaneously both the d e s i r a b l e and u n d e s i r a b l e a t t r i b u t e s of a p a r t i c u l a r type of behavior, (p. 3 1 5 ) The p o s i t i v e reframing a r t i c l e p resents two i n t e r e s t i n g case examples. In the f i r s t case, a 1 2 year o l d boy was d i s p l a y i n g i s o l a t i v e behavior, and a d i r e c t approach encouraging him to i n t e r a c t with peers proved u n s u c c e s s f u l . The authors, r e a l i z i n g t h a t " r e s i s t a n c e " r e q u i r e d an N of at l e a s t two, decided to focus on the p o s i t i v e a spects of the boy's stubborn i s o l a t i v e behavior. They t o l d the boy that, a f t e r thinking about i t , they had changed t h e i r mind about his behavior and thought i t was a good attempt to "get in touch with his sad fe e l i n g s " . They also stated that u n t i l he got to know himself well he wouldn't be able to s a t i s f a c t o r i l y interact with others. The boy was understandably confused i n i t i a l l y by the message and within a couple of days, he dramatically changed his behavior. The authors report that he began to spend v i r t u a l l y a l l of his free time with peers and he f e l t better about himself and more in control of his behavior. Notice that t h i s p o s i t i v e reframe was on the individual l e v e l ; i t does not mention other members of the boy's family or hospital system. The second s i g n i f i c a n t case example i s a paradoxical intervention that belongs to the t h i r d or transactional l e v e l . Faced with the ever present problem of intense peer c o n f l i c t on a hospital unit, the authors came up with a reframe that was directed at the whole group. They relab e l l e d peer c o n f l i c t as an expression of a f f e c t i o n and caring using the rationale that "you don't f i g h t with people that you don't care about" (Jessee & L'Abate, 1980 p. 316). The children adamantly denied the v a l i d i t y of the r e l a b e l l i n g but c o n f l i c t such as scapegoating reportedly dropped off s i g n i f i c a n t l y . 6 7 In each of the above cases, the reframing created a c o n f l i c t for the c h i l d ; behavior that was previously considered undesirable took on a po s i t i v e meaning and the c h i l d was actually encouraged to display i t . It may be hypothesized that the purpose or intention the c h i l d had for displaying the behavior in the f i r s t place, whether conscious or unconscious, i s d i s q u a l i f i e d by the new meaning attributed to i t , thus leaving the c h i l d i n a state of confusion about whether or not to continue the behavior. In many ways, t h i s view of the dilemma facing the individual who has been presented with a paradoxical message reminds one of Festinger's ( 1 9 5 7 ) c l a s s i c theory of cognitive dissonance. Festinger's theory suggests that dissonance i s created whenever one cognitive element (belief about oneself, one's behavior or the environment) c o n f l i c t s with another cognitive element. The theory suggests that at least one of these cognitive elements must refer to oneself. The assumption being that the individual cannot tolerate the discomfort caused by these two c o n f l i c t i n g cognitive elements and so he acts in a manner so as to make the two elements consonant. For the c h i l d whose behavior has been p o s i t i v e l y reframed, he can either a) disregard the new d e f i n i t i o n and continue displaying the behavior, or b) accept the new d e f i n i t i o n and a l t e r his behavior so as to be consonant with the new meaning attributed to i t . 6 8 Jessee and L'Abate ( 1 9 8 0 ) report that t h e i r most successful reframes on an in-patient unit addressed the entire problem system. In other words, reframes which were transactional, involving a l l the members of the system, provided the most impact and dramatically altered the behavior of the group members. These authors caution that p o s i t i v e reframing i s un l i k e l y to be e f f e c t i v e with children who have not reached the concrete operation stage of cognitive development which emerges at the age of 7 or 8 (Inhelder & Piaget, 1 9 6 4 ) . Bergman ( 1 9 8 0 ) describes the use of paradoxical interventions to change the resis t a n t behaviors of community home resistants who are considered c h r o n i c a l l y disturbed or retarded. The interventions used were i n i t i a t e d a f t e r more t r a d i t i o n a l behavioral approaches had proved unsuccessful. Bergman assumes that symptoms displayed by residents serve some function for them and are maintained by the emotional system within the community home. He also introduces the concept of "context r e p l i c a t i o n " , suggesting that the same symptoms that the resident displays in the community home may have served a si m i l a r function when the resident was l i v i n g i n an i n s t i t u t i o n or, p r i o r to that, when the resident was l i v i n g with his family of o r i g i n . 69 Bergman assumes that residents of the home are not "helpless" with respect to much of the symptomatic behavior they are displaying. He suggests that symptomatic behavior in a r e s i d e n t i a l home i s often used in a manipulative way, with the residents receiving some "secondary gain" when displaying i t . A good example of t h i s dynamic i s provided in a case study of a 30 year old man named Brian (Bergman, 1980, p. 6 8 ) . Brian had been doted on and i n f a n t i l i z e d during a 20 year stay at a state school for the retarded. Much of his behavior consisted of subtle and not so subtle i n v i t a t i o n s to others to take care of him and treat him d e l i c a t e l y . After t r y i n g more di r e c t behavioral approaches to change his dependent behavior the s t a f f decided to use a paradoxical intervention. The paradoxical approach consisted of f i r s t apologizing to Brian for trying to make him act l i k e an adult when, afte r a l l , he "was a 3 year old c h i l d trapped i n the body of a man" (p.6 8 ) . For the next three days the s t a f f treated Brian l i k e a 3 year old; putting him to bed at 7 pm, making him take naps i n the afternoon, and cutting up his meat and mashing his food. After a while Brian responded angrily to the treatment he was receiving and complained to his friends. Within three days the author reports that Brian "metamorphosized" into f u l l adulthood. He became more assertive, organized, and well-groomed and refrained from looking to others for help and 7 0 support. Bergman ( 1 9 8 0 ) states that two months afte r the intervention was introduced Brian was l i v i n g in an apartment in the community i n a f u l l y grown state. One additional strategy which the author used in the above case i s predicting a relapse. After Brian began to show some s i g n i f i c a n t behavioral changes they t o l d him that they were s t a r t l e d by these changes and didn't expect them to l a s t . This strategy further heightens the challenge to prove the s t a f f wrong with a move away from dependency and a " f l i g h t - i n t o -health". Bergman ( 1 9 8 0 ) offers an interesting explanation for the effectiveness of his paradoxical interventions. He suggests that by prescribing a behavior and reframing the motivation for i t , the s t a f f are able to assume a one-up position within the house hierarchy. Children who are acting out and are highly resistant to outside interference f u n c t i o n a l l y take control of the power hierarchy within the therapeutic system. By reframing the resistant behavior and prescribing i t , the s t a f f regain control and thus assume t h e i r normal status in the hierarchy of a d u l t / c h i l d transactions (Madanes, 1 9 8 0 ) . This explanation focuses on the resistance within the system; i f the s t a f f continue to push for change and the c h i l d refuses to change, the s t a f f appear powerless. However, i f the s t a f f 71 encourages the resistance and, in a sense, authorizes the troublesome behavior, they disarm the children of t h e i r means of c o n t r o l . This explanation would suggest that reframing may be the treatment of choice when a power struggle develops between s t a f f and children. Williams and Weeks (1984) demonstrate some of the possible uses of paradoxical methods in a school setting with pre-adolescent and adolescent children. The authors suggest that a straightforward approach to therapy be t r i e d f i r s t and, i f resistance i s encountered, a paradoxical intervention may then be appropriate. Symptom pres c r i p t i o n and paradoxical prediction are reported as being very useful interventions with an adolescent population. With paradoxical prediction the therapist predicts that the student w i l l l i k e l y continue to display the problem behavior for some time to come. The author suggests that t h i s sort of intervention works well with highly resistant and oppositional individuals who w i l l a l t e r t h e i r behavior just to prove others wrong. The four a r t i c l e s reviewed above are the only examples reported to date that examine the use of strategic-systemic methods i n a setting other than the c l i n i c i a n ' s o f f i c e . The case examples presented reveal the ingenuity and c r e a t i v i t y of the authors i n adapting strategic/systemic methods to f i t a new 72 therapeutic context. One issue which these studies f a i l to address i s the d i s t i n c t i v e l y d i f f e r e n t role that r e l a t i o n s h i p plays i n conventional c h i l d care as compared to the role i t plays in the strategic/systemic approach. Before concluding the review section of t h i s thesis, l e t us examine t h i s important issue further. As was mentioned e a r l i e r , most of the l i t e r a t u r e representing the established approaches to r e s i d e n t i a l treatment suggest that a nurturing, supportive r e l a t i o n s h i p i s a key ingredient of therapeutic success (Bettelheim, 1974; Jones, 1980; Brendtro & Ness, 1 9 8 3 ) . Brendtro (1969) describes the development of a r e l a t i o n s h i p as the formation of human bonds v i a t r u s t , empathy and communication s k i l l s . He goes on to state that "relationship" within c h i l d care i s the active agent of change; with the development of bonds to f a c i l i t a t e behavior change. In the great majority of l i t e r a t u r e on r e s i d e n t i a l treatment there seems to be agreement that the s t a f f - c h i l d r elationship i s the essence of c h i l d care (Brendtro & Ness, 1983; Kruger, 1980; Pierce, 1982; Trieschman, 1969; Parry, 1 9 8 4 ) . When we look to the l i t e r a t u r e on strategic/systemic theory we f i n d that "relationship" does not take a central therapeutic role as an agent for change. In f a c t , the 73 strategic/systemic l i t e r a t u r e has very l i t t l e to say about the rela t i o n s h i p between c l i e n t and therapist. The best description of the systemic position in regards to the re l a t i o n s h i p issue i s put forward by P a l a z z o l i et a l . (1980). They suggest that to work systemically the therapist should behave i n a manner so as to be perceived as a neutral f i g u r e . The therapist should not take sides with any members of the family. According to the Milan group the therapist's personality does not act as an agent for change (Palazzoli et a l . , 1978a). Many r e s i d e n t i a l treatment programs actually encourage and foster the dependent behavior of t h e i r residents. Maier (1981) states "Group care programs have to be structured in such a way that c h i l d care workers have time, know-how, and above a l l , immediate support for dependency nurturance" (p. 31). This "dependency nurturance" takes the form of encouragement (to try new behaviors), empathy, advice giving and physical comfort. This approach contrasts sharply with the "no-change" position often taken by the strategic therapists. Unlike the position taken by conventional c h i l d care workers, who encourage change and accept the role of a f a c i l i t a t o r of change, the strategic therapist often takes an equal and opposite po s i t i o n , encouraging the status quo and avoiding c r e d i t for any change that may occur (Watzlawick et a l . , 1974). This major 74 difference of opinion over the role of relationship as an agent of change w i l l be discussed further in a la t e r section. As we can see from the above review, l i t t l e has been written on the use of strategic/systemic methods i n the r e s i d e n t i a l setting. Of the few a r t i c l e s that have been reported, there i s no mention of how strategic/systemic methods can be incorporated into the general philosophy of r e s i d e n t i a l treatment. The adoption of these new methods into r e s i d e n t i a l treatment inevitably produces some the o r e t i c a l complications. Following the case study presentation of a selection of interventions used at Vanhouse some of these t h e o r e t i c a l complications w i l l be described. 7 5 CHAPTER 3 - METHOD OF STUDY THE CASE STUDY AS A METHOD OF RESEARCH The case study i s a f a i r l y common research strategy in psychology, sociology, p o l i t i c a l science and planning. The case study approach was s p e c i f i c a l l y chosen for the present research endeavour for i t s a b i l i t y to retain the h o l i s t i c and meaningful c h a r a c t e r i s t i c s of the r e a l - l i f e events that occurred at the Vanhouse Treatment Home. The type of questions asked in t h i s thesis determined the selection of the research method. The purpose of t h i s thesis i s to describe the use of strategic/systemic methods in a novel setting; the r e s i d e n t i a l treatment home. Previous l i t e r a t u r e on t h i s topic i s r e l a t i v e l y non-existent. Therefore, the aim of the present study i s to address the "how" questions that pertain to the implementation of a unique treatment approach. These questions, which were stated in the introduction, refer to how the strategic/systemic methods were implemented and how the r e s i d e n t i a l context influenced that implementation. In addition to "how" questions, t h i s thesis i s concerned with "why" questions that contribute to the development of theory. "Why" questions are explanatory i n that they attempt to connect the results to the established theory. As we can see, the questions posed by the thesis, which follow d i r e c t l y from the stated goals, determine i t s structure and focus. According to Yin ( 1 9 8 4 ) , the case study i s the research method of choice when a "how" or "why" question i s being asked about a contemporary set of events, over which the investigator has l i t t l e or no control. Yin, i n his book "Case Study Research" ( 1 9 8 4 ) , provides an excellent discussion of the case study method and helps to d i s t i n g u i s h i t from other research strategies. Yin defines the case study as; ...an empirical enquiry that investigates a contemporary phenomenon within i t s r e a l - l i f e context; when the boundaries between phenomenon and context are not c l e a r l y evident; and i n which multiple sources of evidence are used. (pg. 23) Unlike an experimental research strategy, which de l i b e r a t e l y divorces a phenomenon from i t s context, the case study attempts to capture the phenomenon in i t s natural s e t t i n g . The experimental s i t u a t i o n requires the researcher to i s o l a t e a few s i g n i f i c a n t variables and "control" the context in order that quantitative statements may be made concerning 7 7 the rela t i o n s h i p between those s i g n i f i c a n t variables. The case study, by contrast, takes a more h o l i s t i c view of the phenomenon and attempts to illuminate the s i g n i f i c a n t variables and make q u a l i t a t i v e statements concerning the rel a t i o n s h i p between them. Yin (1984) states that t r a d i t i o n a l l y the single- and multiple-case study has been viewed as a less desirable form of enquiry as compared to either experiments or surveys. He c i t e s three common complaints that have been l e v e l l e d against the case study method. The f i r s t complaint focuses on the lack of rigor that has been associated with the case study. Yin acknowledges that many case studies have been g u i l t y of sloppy research methods and that biased views have previously tainted the findings and conclusions. However, he notes that t h i s c r i t i c i s m i s not unique to the case study, as bias can also enter into the conduct of experiments and other research strategies. The second common complaint concerns the s c i e n t i f i c g e n e r a l i z a b i l i t y of the case study method. G e n e r a l i z a b i l i t y refers to the research study's external v a l i d i t y . T y p i c a l l y , c r i t i c s who question the g e n e r a l i z a b i l i t y of the case study are i m p l i c i t l y contrasting the si t u a t i o n to survey research. If a sample i s selected c o r r e c t l y i n survey research then i t should 7 8 r e a d i l y generalize to a larger universe. Yin ( 1 9 8 4 ) states, however, that t h i s analogy to samples and universes i s incorrect when dealing with case studies. He points out that survey research r e l i e s on s t a t i s t i c a l generalizations, whereas case studies (as with experiments) re l y on a n a l y t i c a l generalizations. With a n a l y t i c a l generalizations the researcher's goal i s to generalize a p a r t i c u l a r set of results to some broader theory. Case studies, then, do not represent a "sample", and th e i r results are generalizable to the o r e t i c a l propositions, not to populations or universes. Relating the above discussions to the case at hand, namely the Vanhouse treatment approach, the results obtained at Vanhouse are not intended to be used as a representative sample of a larger population of r e s i d e n t i a l treatment approaches. Instead the results are intended for the purpose of expanding and generalizing theories; s p e c i f i c a l l y those which are concerned with r e s i d e n t i a l treatment and the strategic/systemic orientation to behavioral change. The t h i r d frequent complaint that Yin ( 1 9 8 4 ) notes i s that case studies take too long and result in massive, unreadable documents. With reference to the present case, where the participant-observation strategy was used to c o l l e c t data, the time investment was considerable. However, as Yin points out, 7 9 a good case study does not require the investigator to spend an inordinate amount of time i n the " f i e l d " in order to c o l l e c t s u f f i c i e n t data. As for the "unreadability" of the case study, Yin ( 1 9 8 4 ) suggests that the prospective investigator should read his book to solve t h i s problem. THE SINGLE-CASE DESIGN There are both single- and multiple-case designs within the case study method. Yin ( 1 9 8 4 ) states that there are a number of circumstances that dictate the use of the single-case design, including; the c r i t i c a l case, the extreme or unique case, and the revelatory case. The present study i s c l e a r l y an example of the revelatory case. The revelatory case study may be described as an observation and analysis of a phenomenon previously inaccessible to s c i e n t i f i c observation. An investigation of the Vanhouse treatment method i s revelatory i n that an approach of t h i s type has never previously been attempted or described. The purpose of the study i s to reveal the nature of the phenomenon and to test t h e o r e t i c a l propositions that have previously been suggested i n the associated l i t e r a t u r e . 8 0 When using the case study method i t i s important to define the s p e c i f i c unit of analysis. The unit of analysis refers to the parameters of the phenomenon under investigation or the pa r t i c u l a r focus that the study takes. In the present study the focus i s on the use of strategic/systemic methods in a re s i d e n t i a l setting. The unit of analysis includes the treatment home as the context, but the "case" cannot be defined as the "treatment home" i t s e l f . I f , for example, the unit of analysis had been the "home" in general, then the descriptions would have focused on a l l aspects of the behavior that occurred at Vanhouse. However, not a l l of the behavior that occurred at Vanhouse i s of equal importance to the focus of the study. The behavior which i s of p a r t i c u l a r interest concerns the implementation and use of strategic/systemic methods i n the r e s i d e n t i a l setting. In order that the strategic/systemic approach i s adequately understood certain contextual elements must be described. This explains the description of the previous treatment approach at Vanhouse as well as some of the other descriptions which are less central to the strategic/systemic approach. As was stated e a r l i e r , the present study i s a single-case design. Using Yin's ( 1 9 8 4 ) terminology, the study i s an "embedded" rather than a " h o l i s t i c " design. A h o l i s t i c design would describe and analyze the global nature of the treatment 81 approach at Vanhouse, while the embedded design focuses on c e r t a i n aspects, or "subunits", of the approach. These subunits are described separately under headings such as; Relationships, Rules and Consequences, Interventions, etc. The subunit which receives the most attention i s the "Interventions", which includes the description of actual case examples. Although the interventions are presented as "case examples", the design should not be confused with a "multiple-case design". The intervention examples are presented for the purpose of illuminating the larger unit of focus, the strategic/systemic approach, and for extrapolating propositions to broaden the theoretical framework. A multiple-case design, in contrast, would focus almost exclusively on the intervention case examples, with only a b r i e f description of the other aspects of the approach. For the present single-case design the interventions are provided in order to make the study more robust. A detailed description of the strategic/systemic approach i n operation helps to distinguish i t from other r e s i d e n t i a l approaches and provides data that can be used to formulate some general t h e o r e t i c a l propositions. DATA COLLECTION According to Yin (1984) case studies may be based on six d i f f e r e n t sources of data c o l l e c t i o n ; documentation, 8 2 interviews, participant-observation, d i r e c t observation, archival records, and physical a r t i f a c t s . The present study makes use of the f i r s t three sources of evidence. The documentation that was analyzed included; the d a i l y log reports for each of the residents, a "message" book which was used to record the strategic/systemic verbal interventions, minutes from weekly s t a f f meetings, progress reports, and history/demographic information that had previously been recorded for each of the residents. The d a i l y log reports consisted of a written description of the residents' behavior, which was recorded in separate note books for each resident. These logs were used to ensure that the s t a f f were aware of the "events" occurring in the house and to monitor the progress of the resident through the treatment process. As a source of evidence for the case study the logs were analyzed for indications of behavioral change, and to determine how the s t a f f handled s p e c i f i c issues that emerged. The "message book" was an innovation in the approach that was i n i t i a t e d by the author of the thesis as a p a r t i c i p a n t -observer. The purpose of t h i s book was to record the strategic/systemic verbal interventions and the i n i t i a l reactions of the residents to these interventions. The case 8 3 examples that are provided in the results chapter were selected from the numerous interventions that were recorded in the message book. The message book i s described further in the results chapter. Minutes from the weekly s t a f f meetings provided a good source of evidence of the developing treatment philosophy at Vanhouse. These meetings, which were attended by the author as a s t a f f member, functioned as an arena for open discussion of the strengths and weaknesses of the treatment approach. Adjustments to the approach and the formulation of strategic/systemic interventions also occurred during these meetings. For these reasons, the weekly s t a f f meetings proved to be an invaluable source for gathering case study evidence. The interviews that were used to gather information were of an open-ended nature. The coordinator of the program and a family worker were interviewed informally regarding t h e i r perspectives on the developing approach. The source of evidence which provided the most information was the ongoing observations that the author had as a participant-observer. The author was employed as a c h i l d care worker i n the home, two days a week, for approximately six months. Much of the information that was used i n the case 8 4 study came from observing and p a r t i c i p a t i n g i n the weekly s t a f f meetings. The author also had the opportunity to help formulate and deliver strategic/systemic interventions. The quali t y and accuracy of the investigation was s i g n i f i c a n t l y enhanced as a result of t h i s " i n s i d e r ' s " view of the phenomenon under study. Of course, as Yin ( 1 9 8 4 ) reminds us, the participant-observation role may p o t e n t i a l l y produce certain biases. Due to the fact that the present study i s descriptive in nature, as opposed to evaluative, these biases are hopefully kept to a minimum. I f , for instance, the study involved making comparisons between two d i f f e r e n t treatment approaches, then the author's r e l a t i v e " o b j e c t i v i t y " would be a more serious concern. DATA ANALYSIS According to Yin ( 1 9 8 4 ) , when conducting a case study analysis i t i s important to have a general analytic strategy. The analysis in the present thesis i s based on a descriptive framework, which helps to organize the case study. This framework covers the various elements or "subunits" of the case; i . e . , "The Residents", "The Staff", "Interventions", etc., and each of these elements i s examined in l i g h t of the i n i t i a l questions posed by the thes i s . 8 5 In addition to the descriptive analytic framework, t h i s thesis also r e l i e s on some general t h e o r e t i c a l propositions to guide the analysis of the data. These propositions were stated in problem form in the introductory chapter under the following headings; "The Identified Patient Problem", "The Surrogate Parent Problem", "The Problem of Resistance", and "The Problem of Control and D i s c i p l i n e " . In the concluding chapter the results obtained from observations of the Vanhouse approach are tested against the theoreti c a l propositions derived from the existing l i t e r a t u r e . The ultimate goal in the analysis of the data i s to accurately describe the phenomenon under study and formulate hypotheses that contribute to the development of theory. The descriptive framework and the structure provided by the i n i t i a l t h e o r e t i c a l propositions helps to focus the analysis and provides organization for the entire case study. LIMITATIONS As was stated e a r l i e r the present case study r e l i e s on analytic generalization as opposed to s t a t i s t i c a l generalization. In essence t h i s means that the results and conclusions of the study are generalizable to the broader theory of r e s i d e n t i a l treatment and systems theory. If the study were based on s t a t i s t i c a l generalization then some comparative, quantitative statement could be made about the 8 6 r e l a t i v e success of the approach. However, the purpose of the study was not to evaluate the Vanhouse approach, but to understand and i d e n t i f y the s i g n i f i c a n t variables associated with the implementation of a novel treatment approach in the r e s i d e n t i a l context. In a very real sense, the study represents a "test case" for the theory suggested by the r e s i d e n t i a l treatment and strategic/systemic l i t e r a t u r e . The Vanhouse s t a f f ' s interpretation of the strategic/systemic l i t e r a t u r e represents a potential l i m i t a t i o n of the study. If t h e i r interpretation and implementation of the theory i s an inaccurate representation, then the study f a i l s as a v a l i d "test case" of that theory. F i n a l l y a note about how the results can be used by other investigators and p r a c t i t i o n e r s . The present study w i l l help to focus future investigations in the r e s i d e n t i a l treatment f i e l d and, hopefully, w i l l provide guidelines for the p r a c t i t i o n e r who wishes to implement a si m i l a r approach. In reference to future investigators, a r e p l i c a t i o n of the r e s u l t s w i l l help to determine whether the strategic/systemic theory's propositions are correct, or whether some alte r n a t i v e set of explanations might be more relevant. 8 7 CHAPTER 4 - RESULTS The purpose of t h i s chapter i s twofold. The f i r s t section i s concerned with the r e s i d e n t i a l context; highlighting those aspects of the approach which distinguish i t as a systemic orientation to r e s i d e n t i a l treatment. The second major section deals with the strategic/systemic interventions themselves and t h e i r place within the overall treatment plan. THE DEVELOPMENT OF A SYSTEMIC APPROACH As was stated e a r l i e r , the Vanhouse treatment approach that existed p r i o r to the introduction of strategic/systemic methods was primarily relationship based with an emphasis placed on providing the residents with clear, consistent expectations for t h e i r behavior. An underlying assumption of th i s previously established approach was that residents would begin to a l t e r t h e i r inappropriate behavior as a response to the expectations and d i s c i p l i n e applied by the treatment s t a f f . In order to have an impact on the residents' behavior the s t a f f made an e f f o r t to develop strong, supportive relationships with the adolescents. The development of these relationships was based on the premise that close, interpersonal relationships are inherently therapeutic. 8 8 The previously established approach may be described as l i n e a r , or using systems language, one that encourages f i r s t -order change solutions (Watzlawick, et a l . , 1 9 7 4 ) . First-order change refers to change within a given system; i t i s a change in quantity, not q u a l i t y . First-order change involves using the same problem-solving strategies over and over again (Weeks & L'Abate, 1 9 8 2 ) . Typical d i s c i p l i n a r y action i s based on a theory of f i r s t - o r d e r change. For example, some behavior i s displayed by an adolescent which i s considered inappropriate, and the conventional response by parents or s t a f f i s to apply a consequence to act as a deterrent. If the inappropriate behavior occurs again then the same consequence or a more severe consequence, i s administered in a step-wise fashion. The s t a f f at Vanhouse became d i s i l l u s i o n e d and frustrated with the conventional, f i r s t - o r d e r , d i s c i p l i n a r y responses to the inappropriate behavior of the residents. Although t h i s kind of d i r e c t intervention may be r e l a t i v e l y successful with adolescents who are s t i l l residing with t h e i r family of o r i g i n , the Vanhouse s t a f f were of the opinion that in a r e s i d e n t i a l setting these interventions were inadequate and i n some cases countertherapeutic. One of the reasons why d i r e c t or f i r s t - o r d e r change solutions were thought to be inadequate may be attributed to 8 9 the profound resistance exhibited by the residents. I f , for example, an oppositional adolescent repeatedly f a i l e d to return on time for curfew then progressively d i s c i p l i n a r y consequences would simply heighten the adolescent's rebellious nature and disturb the treatment relationship by creating an intense power struggle. The s t a f f also questioned whether d i r e c t , d i s c i p l i n a r y measures produced any long-lasting, i n t e r n a l i z e d change in the adolescent's behavior. In order to avoid countertherapeutic power struggles and to act as a catalyst for s i g n i f i c a n t , long-lasting change the s t a f f focused on second-order solutions to the residents' behavioral d i f f i c u l t i e s . Second-order change refers to a change in the system i t s e l f (Weeks & L'Abate, 1 9 8 2 ) . In other words, instead of tr y i n g to promote change by staying within the system, the system i t s e l f i s altered. By a l t e r i n g the structure and meaning of the interaction between the members of a system a q u a l i t a t i v e s h i f t occurs. In the r e s i d e n t i a l context the "system" includes the relationship between the residents and the s t a f f . When f i r s t - o r d e r change solutions are attempted in the r e s i d e n t i a l setting the r e l a t i o n s h i p between resident and s t a f f i s defined as one where the s t a f f encourages, di r e c t s or demands change from the resident. If the resident complies with the s t a f f wishes then there has been a quantitative change in the behavior, i . e . the behavior i s displayed less 9 0 frequently, however the structure of the interaction between the two parties remains constant. In order for second-order change to occur there must be a change in the structure of the inte r a c t i o n , i . e . a change in the system i t s e l f . The change in the Vanhouse system occurred when the s t a f f assumed the paradoxical role of not being a "changer". That i s , unlike conventional c h i l d care workers, the Vanhouse s t a f f assumed the paradoxical position of encouraging the status quo by p o s i t i v e l y connoting, predicting or prescribing the problem behavior. To be s p e c i f i c , a s h i f t in the Vanhouse system's structure occurred when the relationship between s t a f f and resident was q u a l i t a t i v e l y changed. When the relationship structure within a system changes the meaning attributed to that r e l a t i o n s h i p also changes. As we sh a l l see in the following section, structure and meaning are inextricably t i e d together. The following sections describe the attempts made by the Vanhouse s t a f f to a l t e r t h e i r approach so that i t would be consistent with a systemic orientation to behavioral change. These descriptions are followed by s p e c i f i c examples of the strategic/systemic interventions employed at Vanhouse. 91 RELATIONSHIPS Weeks and L'Abate (1982) discuss the properties of an open system. These properties are defined as wholeness, re l a t i o n s h i p and e q u i f i n a l i t y . Wholeness refers to the concept that a system i s more than just a c o l l e c t i o n of parts. It i s a set of interdependent parts operating as a unit. The second property of a system, relationship, refers to the concept that the system can only be understood in terms of the relationship e x i s t i n g among i t s parts. In other words, the parts are defined by each other. For example, the care giver's role only makes sense or acquires meaning within the context of i t s r e l a t i o n s h i p to the individual being cared f o r . The s t a f f at Vanhouse realized the profound importance of how t h e i r relationship was defined r e l a t i v e to each of the other members of the system. I f , for example, the s t a f f by t h e i r actions or behavior cu l t i v a t e d a substitute-parent relationship with the residents then the residents, in turn, would assume a child-parent relationship with the s t a f f . In systems language t h i s concept i s c a l l e d "complementarity" (Watzlawick et a l , 1 9 7 2 ) . The s t a f f at Vanhouse examined t h i s c r u c i a l issue of complementarity and relationship from the larger perspective of 92 treatment goals. The primary treatment goal for almost a l l of the Vanhouse residents was to re-establish a functional r e l a t i o n s h i p between the resident and her family. When the st a f f examined t h e i r r e l a t i o n s h i p with the children they concluded that the development of close, interpersonal relationships would l i k e l y disrupt or in t e r f e r e with the reparative process that would eventually occur between adolescent and parent. In other words, the s t a f f were concerned that the development of t i e s between s t a f f and residents would jeopardize the natural process of separation and attachment that occurs between parent and c h i l d . From a systemic perspective, the dilemma that faced the Vanhouse s t a f f might be described by Watzlawick (1974) as "when the solution becomes the problem". From a conventional standpoint the "attempted therapeutic solution" i s to provide the residents with meaningful, caring relationships as an active agent for change; the understanding being that close interpersonal relationships are inherently therapeutic. However the "attempted solution" becomes the "problem" when the development of these relationships serves to jeopardize the "meta-goal" of re-establishing a functional family unit. In order to avoid being placed in a position that might undermine or block any b e n e f i c i a l interaction between adolescent and parent, the s t a f f decided to re-define t h e i r r e l a t i o n s h i p to the residents. E s s e n t i a l l y t h i s r e - d e f i n i t i o n meant that the s t a f f did not become too involved with the personal l i v e s of the residents and steered clear of any "surrogate parent" kinds of behavior. Although the s t a f f were s t i l l pleasant and generally accessible to the residents they avoided being put in a position where the residents might become dependent or overly involved with them. In doing so the s t a f f hoped that the adolescents would turn to t h e i r families to meet t h e i r needs for belongingness and intimacy and not to the s t a f f . To redefine t h e i r r e l a t i o n s h i p to the residents, the s t a f f primarily changed the level of communication i n the home. Instead of always empathizing or encouraging the residents to talk about t h e i r problems or worries, the s t a f f redirected them to bring up t h e i r concerns in a family therapy session or with t h e i r parents d i r e c t l y . The s t a f f also refrained from asking the residents personal questions or becoming too involved with t h e i r s o c i a l l i v e s . It i s impossible to report on the consequences of the change i n staff/resident relationships with any certainty but some behavioral consequences may be hypothesized. F i r s t of a l l a few of the residents were known to complain that "the s t a f f 9 4 didn't r e a l l y care about them, they were only at the home because they were being paid to be there". A number of the residents were also, on occasion, generally h o s t i l e towards the s t a f f without any apparent reason. And f i n a l l y i t was observed that a few of the residents behaved aggressively when s t a f f were asking for minimal compliance with the house expectations. During a s t a f f retreat that took place approximately seven months from the date when the systemic/strategic approach was i n s t i t u t e d , the s t a f f addressed t h i s issue of rel a t i o n s h i p . The general consensus of the s t a f f was that perhaps t h e i r attempt at disengaging from the residents had resulted in t h i s increase i n h o s t i l i t y directed at the s t a f f . The i n i t i a l treatment goal of avoiding i n t e r f e r i n g with the process of attachment and separation between the adolescents and t h e i r parents may have been successful, however, a by-product of the disengaging may have been t h i s observed increase i n s t a f f -directed h o s t i l i t y . To remedy the s i t u a t i o n i t was decided that s t a f f would present a more engaging presence to the residents. At the same time, the s t a f f were quite determined^ not to engage the adolescents to the extent that they had with the previous treatment approach. It was decided that the relationship that should exist between the s t a f f and resident would be one where 95 the s t a f f were generally supportive and interested in the residents while at the same time avoiding taking on, or being put i n , the position of surrogate parent. As the reader might imagine, i t i s a d i f f i c u l t task, when l i v i n g day to day with adolescents, to engage them to the extent that the rel a t i o n s h i p i s one of caring and genuine int e r e s t without becoming overly involved and encouraging dependent behavior. Of course, the way i n which s t a f f members rela t e to each of the adolescents i s dependent on the individual resident's r e l a t i v e engagement or disengagement with the s t a f f . In some cases, with overly involved residents the s t a f f consciously backed-off in order that the adolescent might become motivated to engage with more " s i g n i f i c a n t others" in t h e i r l i v e s . This relationship issue i s an important element in a systemic/strategic approach to r e s i d e n t i a l care. It appears that the s t a f f encountered a c o n f l i c t in treatment goals; on the one hand, systemic theory would seem to suggest that a neutral, disengaged rel a t i o n s h i p i s required so that the adolescents are not "drawn away" from interaction with t h e i r f a m i l i e s , and on the other hand, from a r e s i d e n t i a l care perspective, a disengaged relationship leads to unresponsive and h o s t i l e behavior on the part of the residents. The s t a f f 9 6 adopted a compromise between these two positions and began to present a more engaging presence while leaving the residents "room to move" so that they might re-establish functional relationships with t h e i r f a m i l i e s . It may be said that the previously established "complementary" rela t i o n s h i p between the s t a f f and residents was substituted for a more "symmetrical" one. The complementary relationship was one where the s t a f f ' s role was defined as nurturing and supportive while the residents assumed the role of those i n need of nurturing and support. A more symmetrical relationship between the two parties existed when the s t a f f refrained from always being in the nurturing r o l e , and the residents, in turn, were free to assume a role other than the vulnerable, supported one. In essence, a more symmetrical rel a t i o n s h i p between the two parties encouraged the residents to draw on t h e i r own strengths and- the strengths of t h e i r f a m i l i e s . Another important relationship that the s t a f f examined from a systemic perspective was the one that existed between the s t a f f and the resident's family. An a r t i c l e by Menses and Durrant ( 1 9 8 7 ) argues that most " t r a d i t i o n a l " models of r e s i d e n t i a l care ignore the context within which adolescents and t h e i r families make sense of placement. They suggest that 9 7 the meaning of placement i s often one that exacerbates feelings of f a i l u r e and removes r e s p o n s i b i l i t y from the family. To remedy the situ a t i o n these authors suggest that the r e s i d e n t i a l s t a f f "frame" the placement as a " r i t e of passage", which marks the change of context to one in which the family i s able to stand up to the problem together. The s t a f f at Vanhouse were also aware of the disempowering aspect of placement and avoided triangulating themselves with family members. What i s meant here by "triangulating" i s that the s t a f f avoided assuming or being put i n the position of taking over the r e s p o n s i b i l i t y for "curing" the adolescent in i s o l a t i o n from the family unit. Triangulation refers to the struggle that can develop between the s t a f f , family and adolescent. To avoid t h i s struggle, the s t a f f made sure that whenever communicating with family members they acknowledged and respected the family's i n t e g r i t y and resources. For example, to communicate a simple message of respect, the s t a f f consulted with the residents' parents about an appropriate bedtime for the adolescents. Clothing money supplied by the ministry was also passed on to the parents so that they would assume r e s p o n s i b i l i t y for th e i r c h i l d ' s purchases. These and other messages communicated from s t a f f to family members functioned to maintain the family's i n t e g r i t y and encouraged t h e i r p a r t i c i p a t i o n i n the solution to the family problem. 9 8 Another relationship which required examination when providing treatment from a systemic perspective was the rel a t i o n s h i p of the s t a f f to the larger system which included the community resources and ministry personnel. Treatment goals and interventions within the home may contradict with those planned by workers in the f i e l d . The s t a f f at Vanhouse cl o s e l y monitored both the response to t h e i r interventions by the outside system and the independent actions taken by workers in the f i e l d that might a f f e c t the residents. When working from a systemic perspective, the s t a f f must be aware of, and not underestimate, the potential impact of a l l the members of the resident's system; family, peers, s t a f f and community resources. RESISTANCE As "reluctant c l i e n t s " , adolescents provide an immense challenge to those in the position of administering treatment. For the adolescent, change or compliance with treatment expectations may be interpreted as d i s l o y a l t y to her family. The resident, by a l t e r i n g her inappropriate behavior, may fe e l that she i s i m p l i c i t l y suggesting that the s t a f f are more successful at "parenting" her than her own parents were. In addition, the resident l i k e l y f e e l s obligated to protect the family's status quo by continuing to play her part in the family "drama" (Hoffman, 1981). One way of dealing with t h i s extreme resistance i s described l a t e r in the section on interventions. In addition to the s p e c i f i c interventions described l a t e r , the s t a f f adopted a position in r e l a t i o n s h i p to the residents which helped to minimize the resistance factor. In practice, t h i s meant that the s t a f f refrained from "overpowering" or d i r e c t i n g the residents to behave in a cer t a i n way. When intervening with a resident's behavior the s t a f f made i t clear to the adolescent that she was r e a l l y the only one who could decide what was best for her. In t h i s way the s t a f f did not remove the r e s p o n s i b i l i t y for behavior from the adolescent. Another type of resistance encountered at Vanhouse was provided by the adolescent's peer culture. The Guided Group Interaction approach described e a r l i e r focuses on the powerful influence of t h i s peer culture and attempts to u t i l i z e t h i s force to a l t e r the behavior of the residents. At Vanhouse, the s t a f f were aware of how d i f f i c u l t treatment could become when the residents "banded together" and viewed the home as an "us" (residents) versus "them" (staff) s i t u a t i o n . It may be hypothesized that adolescents in care tend to perceive the s t a f f as the "enemy" because i t helps to develop a cohesive, group f e e l i n g amongst the residents. To minimize the 100 detrimental e f f e c t s of t h i s s t a f f vs. residents phenomenon, the s t a f f at Vanhouse were careful to p o s i t i v e l y connote the process of developing group "togetherness" and, at the same time, avoided encouraging any perception that the s t a f f were in an adversarial role to the residents. One example of how they avoided t h i s perception has to do with consequences for inappropriate behavior. In r e s i d e n t i a l settings when a p r i v i l e g e such as the use of the stereo i s being abused by a number of residents, a t y p i c a l consequence might be to withdraw the use of that p r i v i l e g e for the entire house. The outcome of t h i s intervention might be 1) the residents use t h e i r peer influence to discourage any further misuse of the stereo, or 2) the residents band together and d i r e c t t h e i r h o s t i l i t y at the s t a f f by further misuse and disregard of house expectations. The s t a f f at Vanhouse were careful not to use t h i s kind of intervention when they suspected the residents might respond i n t h i s l a t t e r manner. It was important that s t a f f were aware of and knowledgeable of group dynamics i n order to adequately assess what type of intervention would be most appropriate. From a general standpoint, resistance i n the home was dealt with by e s s e n t i a l l y t r y i n g to sidestep the issue altogether. As was reported e a r l i e r , Jessee et a l . (1982) point out that "resistance requires an N of at least two". By not showing up for the "battle of w i l l s " the s t a f f were able to 101 minimize the "us and them" phenomenon t y p i c a l of r e s i d e n t i a l care. RULES AND CONSEQUENCES In order to avoid i n s t i t u t i o n a l i z i n g the house, the s t a f f were concerned about keeping the rules simple and p r a c t i c a l . To avoid any power struggles associated with house rules, the s t a f f presented them i n a matter-of-fact manner and explained the necessity for having rules in a r e s i d e n t i a l s etting. The residents were given the opportunity to discuss and question the rules at group meetings, and on occasion, rules were changed i f the need arose. The consequences applied for a f a i l u r e to meet house expectations were as clo s e l y linked to the inappropriate behavior as possible. For example the consequence for abusing house p r i v i l e g e s such as T.V., stereo, cooking f a c i l i t i e s , etc. was a temporary removal of that p r i v i l e g e . If a resident stayed out past curfew, they were expected to return that much e a r l i e r the next night. When a resident was away from the house overnight, they were expected to stay in the house the next night. 102 A general rule of thumb at Vanhouse was to avoid overusing a form of d i s c i p l i n e . In other words i f a resident f a i l e d to return home for a few days, then the s t a f f would not apply a s t r i c t consequence such as grounding for three days. If a resident continued to break an established rule the s t a f f investigated the p o s s i b i l i t y of using a novel intervention rather than progressively increasing the consequences to match the i n f r a c t i o n . This approach to d i s c i p l i n e was in accordance with the theo r e t i c a l position on problem formation and resolution proposed by Watzlawick et a l . (1974). By refr a i n i n g from mechanically applying an apparently unsuccessful sanction, the s t a f f avoided the si t u a t i o n where the "attempted solution becomes the problem". If the s t a f f were to progressively remove a l l of the residents' p r i v i l e g e s as a means of c o n t r o l l i n g inappropriate behavior, then t h i s "attempted solution" might very well lead to a larger problem such as re p e t i t i v e AWOL'ing or i n c o r r i g i b l e damage to the therapeutic rela t i o n s h i p between s t a f f and resident. Whenever a si t u a t i o n arose where the "di r e c t " approach to problem resolution appeared inadequate, that i s , when the application of a standard consequence did not a l t e r the problematic behavior, then the s t a f f would use an " i n d i r e c t " 103 method. An i n d i r e c t method was one that u t i l i z e d a second-order change solution or, what may be c a l l e d , a strategic/systemic intervention. These interventions were used i n Vanhouse both to deal with management kinds of problems and general treatment issues. Of course in a r e s i d e n t i a l setting, management and general treatment issues or goals may overlap considerably. The strategic/systemic interventions are discussed in the next section. Before moving on, l e t us examine the Vanhouse approach for resolving inter-group c o n f l i c t . Frequently, in r e s i d e n t i a l settings, there i s a lot of i n f i g h t i n g amongst the residents about things l i k e s tealing, the use of the phone and the establishment of a "pecking order". Redl (1952) chooses to deal with t h i s kind of c o n f l i c t by ignoring i t . He c a l l s t h i s non-intervention "planned ignoring" (1952, pg. 158). The rationale for t h i s decision i s that ignoring the c o n f l i c t and not i n t e r f e r i n g leads to a resolution of the c o n f l i c t by the residents themselves. Watzlawick et a l . (1974) point out that problems can be mishandled when a change i s attempted regarding a d i f f i c u l t y which i s r e a l l y unchangeable or non-existent. Inter-group c o n f l i c t amongst residents i n a treatment home i s i n e v i t a b l e . If s t a f f were to regularly i n t e r f e r e with the day to day c o n f l i c t s between residents, t h e i r interference would l i k e l y "become the problem". The s t a f f at Vanhouse also adopted a non-interference strategy to deal with roost of the day-to-day c o n f l i c t between the residents. By not i n t e r f e r i n g , they allowed the residents the "space" required to work out t h e i r own interpersonal c o n f l i c t s and they avoided faulty interference that could become part of the problem. Of course i n c e r t a i n circumstances, such as when safety was involved, the s t a f f found i t necessary to intervene and set l i m i t s on the residents' inter-group c o n f l i c t . THE PHYSICAL SETTING The present coordinator of the program at Vanhouse took over the contract to run the house in March of 1980. This contract was negotiated and renewed yearly with the Ministry of Social Services and Housing (MSSH). Included in the contract was the house i t s e l f , which i s owned and maintained by the B r i t i s h Columbia Building Corporation (BCBC). The house i s situated in a r e s i d e n t i a l area and there i s nothing about i t s outward appearance that might i d e n t i f y i t as a treatment home. The coordinator of the home has put in considerable e f f o r t over the years to furnish the house comfortably on a limited budget. The s t a f f attitude towards the furnishings was one of respect, and damaged furniture was 105 attended to immediately. By displaying a respectful attitude towards the surroundings, the s t a f f were i n d i r e c t l y expressing t h e i r respect for the residents. It i s also thought that respect for surroundings was an important attitude for the adolescents to adopt before moving on to independent l i v i n g . Residents were given free access to a l l areas of the house except for the s t a f f o f f i c e . Smoking was only permitted in the dining room. The smoking rule was established both for safety and to provide the g i r l s with an area to s o c i a l i z e with each other and with the s t a f f . The designated smoking area created a center for a c t i v i t y and interaction and provided easy access to the adolescents when an intervention was planned. In summary, then, the physical setting was not underestimated as an important part of the therapeutic environment. By modeling and encouraging respect for the physical surroundings, the s t a f f helped to establish a po s i t i v e attitude towards the home and the residents themselves. THE STAFF As was stated in the introduction there were eleven f u l l time employees at Vanhouse. Six f u l l time c h i l d care workers (usually three men and three women), two overnight workers, two 106 family workers and a coordinator. There were also two people employed as r e l i e f s t a f f . The c h i l d care workers at the home had between f i v e and ten years experience within the f i e l d of r e s i d e n t i a l treatment. Most of the s t a f f had undergraduate university degrees and one of the family workers had previous s o c i a l work experience. The strategic/systemic influence can be largely attributed to a family worker who spent some time studying with the Milan Group in I t a l y . When the strategic/systemic ideas were f i r s t being developed and introduced i n A p r i l ' 86 the c h i l d care s t a f f were by and large unfamiliar with the strategic/systemic l i t e r a t u r e . The s t a f f reported that at t h i s time some of them were wary about having to adopt an approach that they had no experience with. After investigating and discussing the potential for using systemic methods in t h e i r treatment approach, the st a f f were generally supportive and excited about the new changes to the program. In the next chapter the importance of s t a f f attitudes towards the approach w i l l be discussed further. S t a f f i n g at Vanhouse followed a s h i f t work schedule with the c h i l d care workers working from either 7 :00 a.m. to 3 :00 p.m. or 3 :00 p.m. to 11 :00 p.m. The 11 :00 p.m. to 7 :00 a.m. 1 0 s h i f t was covered by an o responsible for any of the c h i l d 7 vernight worker who was not care worker duties. During the weekdays, one of the c h i l d care workers and either the supervisor or family worker were present at the house from 7 : 0 0 a.m. to 3 : 0 0 p.m. In the evenings, and on weekend days, two c h i l d care workers assumed r e s p o n s i b i l i t y for the house. Child care worker r e s p o n s i b i l i t i e s included the following: keeping d a i l y logs on the behavior of each of the residents, writing synoptic reports at regular i n t e r v a l s during the resident's stay and at discharge, monitoring the behavior of the residents and intervening at appropriate times, ensuring the upkeep of the house including shopping and preparation of meals, i n i t i a t i o n and p a r t i c i p a t i o n in weekly resident group meetings, p a r t i c i p a t i n g in weekly s t a f f meetings, and formulating and deli v e r i n g treatment interventions. The two family workers had di f f e r e n t r e s p o n s i b i l i t i e s in th e i r work at Vanhouse. One of the family workers was mainly involved in doing family therapy with the residents of the home and some Outreach c l i e n t s . The other family worker also did family therapy with the residents and Outreach c l i e n t s and, in addition, was responsible for helping to administer and coordinate the home. However both family workers participated in treatment decisions concerning the residents and both 108 attended the weekly s t a f f meetings. The coordinator of the home was responsible f o r , among other things, the f i n a n c i a l administration of the home, taking r e f e r r a l s and acting as a l i a i s o n person with community resources and ministry personnel, and p a r t i c i p a t i n g in the weekly s t a f f meetings. THE RESIDENTS The following information i s provided so that the reader may have an understanding of the background or h i s t o r i e s of the c l i e n t s being treated at Vanhouse. During the eight month period in which the author was employed at Vanhouse, from October 1986 to May 1987, there were a t o t a l of twelve residents placed at the home. No more than six g i r l s resided at the home at any one time and over the eight month period the average was approximately four g i r l s at a time. The age of the g i r l s ranged between 12 and 18, with the average being close to 15 years. It i s safe to say that a l l of the g i r l s were having serious d i f f i c u l t i e s in t h e i r family relationships p r i o r to being placed in care. For eight of the twelve g i r l s , family c o n f l i c t was reported as the most serious presenting problem. Other presenting problems reported at the time of r e f e r r a l included: three of the g i r l s recently had attempted suicide, three had come from families where 109 neglectful situations had occurred (usually as a result of the parents abusing alcohol or drugs), two of the g i r l s were considered to have drug or alcohol problems themselves, and one of the g i r l s had a history of d i f f i c u l t i e s with the law. Background information on the residents revealed that f i v e of the twelve adolescents were members of single parent families at the time they were placed in care. Seven of the residents had come from two parent f a m i l i e s , with only one of these being a blended family. Of the twelve residents only one had been adopted. Before being referred on to Vanhouse six of the g i r l s had spent a b r i e f amount of time in an emergency or assessment resource. Two of the g i r l s had been placed in foster homes pr i o r to t h e i r a r r i v a l at Vanhouse. Three of the g i r l s had spent some time in another treatment center p r i o r to coming to Vanhouse and one had been in two foster homes and a treatment center. Upon a r r i v i n g at Vanhouse and throughout t h e i r stay there, most of the g i r l s attended school sporadically. A few of them did not attend school at a l l and as a result were expected to look for work. One of the g i r l s was known to be working as a pr o s t i t u t e in the Vancouver area. 110 Seven of the twelve g i r l s returned to t h e i r families upon discharge from Vanhouse. Three moved on to other resources within the community and two were discharged to independent 1iving. One of the most common behavior problems exhibited by the g i r l s during t h e i r stay at Vanhouse was AWOL'ing or staying away from the house without permission. Many of the g i r l s were s o c i a l l y involved with friends and acquaintances who spent much of t h e i r time l i v i n g on the streets. Since most of the g i r l s were quite alienated from t h e i r f a m i l i e s , they seemed to get th e i r need for belongingness met on the streets where a cl o s e l y knit, supportive group was ea s i l y accessible. For a number of reasons, AWOL'ing presented the s t a f f with an especially d i f f i c u l t problem. F i r s t of a l l , the interventions used to a l t e r t h i s behavior proved to be by and large unsuccessful. Secondly i t was found that AWOL'ing residents were very d i f f i c u l t to engage in any sort of s i g n i f i c a n t treatment process. And f i n a l l y i t was observed that AWOL'ing was infectious; once one resident AWOL'd other residents were l i k e l y to follow. The s t a f f were of the opinion that i f the residents stayed at the home long enough for a group cohesiveness to develop then AWOL'ing was less frequent. I f , on the other hand, the residents frequently AWOL'd then I l l there were fewer of them present i n the house at any one time and a group cohesiveness was unlikely to develop. Without group cohesion the residents turned to the streets to meet th e i r need for belongingness. INTERVENTIONS Interventions, in a r e s i d e n t i a l context, s p e c i f i c a l l y refer to those actions taken on the part of the s t a f f that were designed to contribute to therapeutic change. This broad d e f i n i t i o n included the day-to-day interaction between s t a f f and residents and the formal treatment messages that were formulated in weekly s t a f f meetings. The focus of t h i s thesis i s on the formal strategic/systemic interventions used at Vanhouse. As was stated e a r l i e r , a major influence on the development of the systemic approach at Vanhouse came from the work of the Milan Group and the the o r e t i c a l formulations provided by Watzlawick and his associates at MRI. These researcher/therapist groups both rely heavily on the use of language as a means of promoting therapeutic change. The Milan Group presents the family with a formal message at the end of the session in an attempt to "capture" the family dilemma and reframe i t in a p o s i t i v e l i g h t (Palazzoli et a l . 1978a). The 112 MRI Group use a number of s t r a t e g i c messages, such as p r e s c r i b i n g the symptom, p r e d i c t i n g a r e l a p s e or d e c l a r i n g impotence, to a l t e r the meaning of the symptoms or to r e d e f i n e t h e i r t h e r a p e u t i c p o s i t i o n i n r e l a t i o n to the c l i e n t . The Vanhouse approach a l s o u t i l i z e d formal messages to reframe r e s i d e n t s ' behaviour and r e d e f i n e the r e l a t i o n s h i p between s t a f f and r e s i d e n t s . One of the most commonly used p a r a d o x i c a l i n t e r v e n t i o n s at Vanhouse was reframing i n the form of p o s i t i v e c o n n o t a t i o n s . A c c o r d i n g to Watzlawick, reframing "...means to change the conceptual and/or emotional s e t t i n g or viewpoint i n r e l a t i o n t o which a s i t u a t i o n i s experienced and to p l a c e i t i n another frame which f i t s the ' f a c t s ' of the same concrete s i t u a t i o n e q u a l l y w e l l or even b e t t e r and thereby changes i t s e n t i r e meaning" (1974, pg. 95). Reframing with p o s i t i v e c o n n o t a t i o n i n v o l v e d examining a r e s i d e n t ' s behavior and " p i c k i n g out" those aspects of the behavior t h a t l i k e l y served a p o s i t i v e f u n c t i o n f o r the r e s i d e n t . In most cases i t was not very d i f f i c u l t to f i n d something about the behavior which c o u l d be put i n a p o s i t i v e l i g h t . P a l a z z o l i (1978a) s t a t e s t h a t the primary f u n c t i o n of p o s i t i v e c o n n o t a t i o n i s to gain access to the systemic model. In o t h e r words, the M i l a n Group use p o s i t i v e c o n n o t a t i o n as a 113 means of joining with the family so that they may then introduce some systemic change. Positive connotation in the r e s i d e n t i a l setting also acted as a means for joining with the residents and avoided the assumption of an adversarial position in r e l a t i o n to t h e i r behavioral d i f f i c u l t i e s . Presumably when the resident was given the message that others understood and accepted the p o s i t i v e elements of t h e i r inappropriate behavior they were then "freed up" to re-examine t h e i r behavior and a l t e r i t accordingly. It would appear that many adolescents display inappropriate behavior simply as a rebellious or oppositional response to adult authority figures. By p o s i t i v e l y connoting, predicting or prescribing the problem behavior the s t a f f removed themselves as targets for the rebellious behavior. Those adolescents who were esp e c i a l l y reactive and oppositional with authority figures were found to be good candidates for paradoxical predictions. In one case with a resident who had an e s p e c i a l l y poor record for school attendance, the s t a f f predicted that she wouldn't be able to attend for more than a few days. This prediction was set up in the following manner: two of the s t a f f l e t themselves be overheard having a discussion concerning a bet that had been made over the g i r l ' s school attendance. The resident in question asked the s t a f f what they were betting about and they t o l d her that one of them 114 thought she would be able to attend school a l l year while the other was sure she would drop out within a week. They t o l d her that they had made a bet between themselves about who would be r i g h t . The resident was very surprised that they were betting about her and declared immediately that she would not quit school. Over the next few months her attendance record improved considerably. The above intervention was an attempt by the s t a f f to use the o p p o s i t i o n a l i t y of the resident in a p o s i t i v e way. When the resident overheard that a s t a f f member was of the opinion that she would be unable to attend school consistently, she was presumably motivated to prove the s t a f f wrong. From a theoretical standpoint i t i s not e n t i r e l y clear why t h i s sort of i n d i r e c t method i s more e f f e c t i v e than simply presenting the resident d i r e c t l y with concerns about her school attendance. Perhaps, because the adolescent may have f e l t she was not improving her school performance for anyone in p a r t i c u l a r , she was motivated to change her behavior. This intervention acted as a challenge to an adolescent who thrived on proving others wrong, es p e c i a l l y when i t came to what she could or couldn't do. This kind of intervention was also used i n a more subtle fashion in what may be c a l l e d a " s p l i t team" message. With a 115 " s p l i t team" message the resident i s t o l d that some of the st a f f have a p a r t i c u l a r opinion concerning the resident's behavior while other s t a f f have a d i f f e r e n t opinion. For instance, a resident may be t o l d that some of the s t a f f f e e l she i s r e a l l y not ready to s e t t l e down and won't be able to meet the house expectations, while the remaining s t a f f f e e l that she has had enough of street l i f e and i s ready to s e t t l e down a b i t . The message hopefully mirrors the dilemma faced by the resident herself and helps her to make a choice between the two options. Notice how the f i r s t option, "street l i f e " , i s framed as a place where people go when they are "not ready to s e t t l e down". By framing i t t h i s way i t i m p l i c i t l y suggests that sooner or la t e r she w i l l be ready to s e t t l e down. FORMULATING INTERVENTIONS A four hour s t a f f meeting was held once a week at Vanhouse. During these meetings, which were attended by a l l s t a f f members and occasionally some other community workers, the agenda would f i r s t cover house business and then each of the residents was discussed i n d i v i d u a l l y . Unlike the "problems" t y p i c a l l y handled by family or individual therapists, which are i d e n t i f i e d by the c l i e n t or c l i e n t s , the problems to be addressed in the treatment home are i d e n t i f i e d by the s t a f f . Those problems which were most pressing were 116 addressed f i r s t and more minor issues were tabled for the next meeting. Some of the t y p i c a l problems or symptoms that were dealt with at Vanhouse include: drug or alcohol problems, AWOL'ing, general oppositional or obnoxious behavior, anxiety and outbursts of anger. The standard procedure during the meetings was to discuss each of the adolescents and, as a group, decide whether an intervention would be b e n e f i c i a l . If the s t a f f f e l t that the problem was a serious one and the adolescent was "ready" to receive a message, then the s t a f f , as a group, would work on the wording of the message. A t y p i c a l example might be the use of a standard p o s i t i v e connotation message that was used in more than one case. If a g i r l had recently moved into the group home and was displaying argumentative, oppositional behavior, then the message might go as follows: "We can see by your arguing and anger at us that you are r e a l l y quite loyal to your parents. We just want to say that we agree that no one could ever replace your parents". This message p o s i t i v e l y connotes the "problem" behavior by associating i t with an admirable, pro-social intention; that of lo y a l t y . By framing the behavior p o s i t i v e l y and acknowledging 117 the bond between parent and c h i l d , the resident w i l l hopefully f e e l less compelled to r e s i s t and reject any interaction with s t a f f . In the words of the Milan group (1978a), an intervention such as th i s allows the s t a f f access to the systemic model. Theoretically once the resident feels secure that the relati o n s h i p between her parents and herself w i l l not be undermined or substituted, she w i l l f e e l less threatened as a relationship develops between herself and the s t a f f . The s t a f f would work on the above message during a meeting and each word would be chosen c a r e f u l l y to " f i t " the individual to whom the message would be delivered. Some of the considerations taken into account when formulating interventions were: 1) does the "language" of the message match the adolescent to whom i t w i l l be delivered? 2) Could the message be interpreted i n a way so as to make i t i n e f f e c t i v e or countertherapeutic? 3) Is the behavior i n question one that was also displayed at home, and i f so, can we formulate the message in a way so as to "capture" the home behavior? 4) Who should deliver the message to get the most impact from i t ? When a "problem" was i d e n t i f i e d the st a f f would make a conscious attempt to view i t from a systemic perspective. To view a presenting problem from a systemic perspective one must take into account the following: 1) What purpose or function 118 might the symptom have for the adolescent? 2 ) Who else may be contributing to the maintenance of the problem? This question focuses on other individuals in the adolescent's system, i . e . family members, peers, or s t a f f , that are part of the problem. 3 ) What solutions have been attempted to resolve the problem thus far? It i s essential when examining a problem from a systemic perspective to investigate how previously attempted solutions may be contributing to the maintenance of the problem behavior. Once the problem had been c l e a r l y i d e n t i f i e d , and the s t a f f had worked out the precise wording of a message, the message (intervention) was recorded i n a "Message Book". This book included the date the message was formulated, the purpose of the intervention and the i n i t i a l reaction ( i f any) that the resident had to the intervention. F i n a l l y , during the meeting a decision was made about which s t a f f would have the opportunity to d e l i v e r the intervention. In some cases, to get the most impact from a message, a s p e c i f i c s t a f f member was chosen to de l i v e r the message. DELIVERING INTERVENTIONS the Once an "Message intervention had been formulated Book" then the s t a f f were ready and recorded in to "deliver the 119 message". The s p e c i f i c manner i n which the message was d e l i v e r e d was an important p a r t of the t h e r a p e u t i c p r o c e s s . The impact of the message may be i n f l u e n c e d by a number of f a c t o r s such as: 1) Who d e l i v e r s the message? 2) When i s i t d e l i v e r e d ? 3) How i s i t d e l i v e r e d ? ( i . e . f o r m a l l y or non-f o r m a l l y ) 4) Is the message d e l i v e r e d p r i v a t e l y or are others present? The s t a f f were of the o p i n i o n t h a t i n c e r t a i n cases the impact of a t h e r a p e u t i c message c o u l d be i n c r e a s e d when a s p e c i f i c s t a f f member d e l i v e r e d i t . The r e l a t i o n s h i p between the r e s i d e n t and the s t a f f , as w e l l as the gender of the s t a f f , are two examples of f a c t o r s that seemed to i n f l u e n c e the r e l a t i v e impact of the message being d e l i v e r e d . Timing a l s o appeared to be an important f a c t o r when d e l i v e r i n g messages. I t was thought t h a t i f a r e s i d e n t had r e c e n t l y experienced a s i g n i f i c a n t event with her f a m i l y , then a message would have more impact i f i t were d e l i v e r e d soon a f t e r the event. Messages were a l s o d e l i v e r e d at the p r e c i s e moment when the r e s i d e n t d i s p l a y e d the i n a p p r o p r i a t e behavior which had become a concern. C l o s e l y l i n k i n g the message and the behavior seemed to e l i c i t a st r o n g i n i t i a l r e a c t i o n from the r e s i d e n t . 120 In c e r t a i n cases the interventions were delivered i n -passing, nonchalantly, while at other times the s t a f f assumed a formal, more serious manner. To present the message in a serious manner the adolescent was usually asked to meet with the s t a f f p r i v a t e l y for a few minutes. Unlike the messages delivered by Pal a z z o l i and her associates, who t e l l t h e i r c l i e n t s that they have a message for them and often d e l i v e r i t in written form, the messages at Vanhouse were usually presented in a less formal manner. On occasion, the s t a f f member who was chosen to de l i v e r the message would t e l l the resident that the s t a f f had been discussing her si t u a t i o n and had come up with a ce r t a i n message. More often the message was delivered in a fashion so as to make i t appear spontaneous. The l a s t factor to mention which seemed to influence the re l a t i v e impact of a message was whether or not the message was delivered p r i v a t e l y . In certain circumstances, l i k e when the presenting problem involved the resident's peers, the s t a f f would deliver the message with s i g n i f i c a n t others present. If the message reframed a resident's behavior then her peers were also introduced to t h i s new outlook on the problem behavior and, presumably, t h e i r behavior would a l t e r accordingly. 121 CASE EXAMPLES In t h i s section a number of actual interventions used at Vanhouse w i l l be described and analyzed. These s p e c i f i c examples were chosen to show the range of interventions used at Vanhouse. Since there was no control group the r e l a t i v e success or f a i l u r e of these interventions was d i f f i c u l t to measure. - However, from a theoretical perspective and from the author's c l i n i c a l judgement and observations, tentative conclusions can be made concerning the strengths and weaknesses of each of the interventions. The personal information given below i s f i c t i t i o u s . Case Example #1 - Caren History and Presenting Problem Caren, age 16 , was placed at Vanhouse a f t e r a b r i e f stay at an assessment home. According to her parents Caren was highly disruptive at home and recently was attending school sporadically. Caren had one s i b l i n g , an older s i s t e r , who from a l l reports was well behaved and "problem-free". When Caren's parents met with the s t a f f at Vanhouse they t o l d us that Caren would l i k e l y have a "honeymoon period" of about three weeks, afte r which she would begin to act up. A report from her previous placement also suggested that Caren was displaying "honeymoon" behavior there and would eventually become disruptive. Prior to formulating the following intervention, Caren's behavior could be described as pleasant, cooperative and a l i t t l e shy. Intervention Upon discussing Caren's sit u a t i o n in the weekly meeting the s t a f f f e l t that she was set up by the parents and the previous placement to begin acting out. Both her parents and the previous placement had suggested to the Vanhouse s t a f f and to Caren that her p o s i t i v e behavior was only temporary and she should therefore get no cred i t for i t . If Caren were to begin acting out then everyone's predictions would come true and Caren's label as a disruptive teenage would be v e r i f i e d . The Vanhouse s t a f f were concerned about the s e l f - f u l f i l l i n g prophecy of t h i s "honeymoon" prediction and decided to intervene with a strategic message. The message was delivered as follows: 1 > nWe understand that you have a reputation of having a honeymoon period of three weeks. 2,We f e e l that i t ' s better to get these things over with quickly, 3'so whenever you're ready i t might be a good thing to get over the honeymoon." 123 Caren's i n i t i a l reaction to the message was, "No! I'm not going to do that here, I l i k e i t here". Analysis ^'This part of the message establishes that the s t a f f are aware of the honeymoon prediction and r e a l i z e that others have pinned t h i s label on her. 2'The second part of the message suggests that the pos i t i v e behavior being displayed i s time limited and, 3'the l a s t part prescribes the problem behavior and i m p l i c i t l y suggests that Caren i s in control of her behavior. Discussion By framing the pos i t i v e behavior as temporary and prescribing the problem behavior the s t a f f placed themselves i n the paradoxical position of encouraging the resident to display the symptomatic behavior. The resistance to change that would be expected form an oppositional teenager was countered with a request for the status quo by encouraging the presenting problem. Caren i s presented with two options: 1) she can begin to display the symptomatic behavior; thereby complying with the s t a f f ' s requests and f u l f i l l i n g the "honeymoon" prediction, or 2) she can continue displaying 124 appropriate behavior and disprove her parents' prediction as well as refusing to comply with s t a f f requests. From her i n i t i a l reaction i t would appear that Caren chose the second option. We can see from t h i s example how the oppositionality of the resident i s u t i l i z e d for therapeutic purposes. How can the resident oppose the s t a f f when the s t a f f make a request for a display of the problem behavior? Only by behaving appropriately, which has i t s own inherent rewards, can the resident prove the s t a f f wrong. On another level the message gives r e s p o n s i b i l i t y for control of the behavior to the resident. The i m p l i c i t suggestion that the problem behavior can be turned on or off gives the behavior new meaning and suggests that i t i s purposeful. This.kind of message, prescribing the symptom, seems to be most e f f e c t i v e with oppositional residents. The fact that the s t a f f makes a request for a display of the problem behavior plays into the rebellious nature of the developing teenager and, i n e f f e c t , removes the wind from her s a i l s . Another i m p l i c i t message within the intervention i s that the s t a f f are not " a f r a i d " of the symptom and accept the resident's "need" to express i t . 125 Throughout Caren's stay at Vanhhouse her behavior remained w i t h i n a c c e p t a b l e l i m i t s . Once she became f a m i l i a r with the s t a f f and house r o u t i n e s she d i s p l a y e d more d i s r u p t i v e behavior than she had i n i t i a l l y . However her behavior was never i n the extreme and she u s u a l l y responded w e l l to the house e x p e c t a t i o n s . Of course i t i s i m p o s s i b l e to determine to what extent the message may have a f f e c t e d Caren's behavior while at Vanhouse. One f i n a l o b s e r v a t i o n about t h i s case i s how the message r e f l e c t s the r o l e t h a t Caren l i k e l y p l a y s i n her f a m i l y . Her parents seemed to g i v e c r e d i t f o r a l l the p o s i t i v e behavior to t h e i r other daughter, and put Caren i n the b l a c k sheep r o l e . The message c h a l l e n g e s Caren to take on a new r o l e and d i s p r o v e her b l a c k sheep s t a t u s . Case Example #2 - Sandra Sandra was 16 when she f i r s t came to l i v e at Vanhouse. P r i o r to placement she had been h o s p i t a l i z e d i n an a d o l e s c e n t p s y c h i a t r i c u n i t and had been diagnosed as c l i n i c a l l y depressed. She had a h i s t o r y of s u i c i d a l i d e a t i o n and had attempted s u i c i d e before being admitted to the h o s p i t a l . 126 Sandra was one of three children of divorced parents and had l i v e d with her mother and mother's boyfriend p r i o r to coming into care. She had a twin brother who s t i l l l i v e d with her father in eastern Canada and an older brother who also l i v e d with her mother. The presenting problem at time of r e f e r r a l was c o n f l i c t at home with her mother and mother's boyfriend. She was also described as depressed, s u i c i d a l and a l c o h o l i c . In her f i r s t couple of weeks at Vanhouse, Sandra appeared quite lethargic and spent a considerable amount of time crying and looking sad. Most of her time was spent i n her room and she avoided s o c i a l i z i n g with both s t a f f and peers. Intervention #1 The most serious concern that the Vanhouse s t a f f had when discussing Sandra's si t u a t i o n was the p o t e n t i a l l y detrimental e f f e c t s of the psychiatric label of depression. The s t a f f had observed that much of her so-called "depressed" behavior was presented in a dramatic manner. Her parents' previously attempted solutions to the problem were to empathize with her and encourage her to f e e l less depressed. Sandra apparently accepted the label of depression and was eager to explain to others how "sick" she was. She had been prescribed a n t i -127 depressants and during her f i r s t few weeks in the house she took them regularly. The f i r s t therapeutic goal addressed by the Vanhouse s t a f f involved reframing the so-called "depression" as sadness. Whenever the opportunity arose the s t a f f would describe Sandra's behavior as sadness instead of depression. She was never discouraged from displaying her "sadness" and the s t a f f did not engage her empathically when she behaved in t h i s manner. Three messages were used to reframe and prescribe the problem behavior. The f i r s t message was delivered while she was crying in her room and went as follows: 1 *"When you are t i r e d of crying you w i l l stop, 2'but some people can cry for years." Sandra's response was, "It's exhausting crying!" and she immediately stopped and had a nap. After sleeping she joined the rest of the residents for dinner and displayed a p o s i t i v e a f f e c t . Analysis ^•'The f i r s t part of the message suggests that her crying i s under her control and predicts that the crying i s time lim i t e d . There i s also the i m p l i c i t message that i f the crying i s under her control then i t must serve some function. 2'The 128 second part of the message places the s t a f f in a neutral position in r e l a t i o n to the symptom by suggesting that she may continue crying i n d e f i n i t e l y . E s s e n t i a l l y t h i s part of the message gives Sandra permission to continue crying. Discussion If one hypothesizes that the "purpose" of the symptom i s to communicate to others a need for nurturance, then accepting the crying and avoiding the "saviour" role l i k e l y confuses the "patient" and makes them re-evaluate t h e i r behavior. The crying and the display of a sad a f f e c t become s o c i a l l y i n e f f e c t u a l when others f a i l to respond i n a supportive manner. This f i r s t message places the r e s p o n s i b i l i t y for control over the "depressed" behavior squarely on Sandra's shoulders. The response to t h i s f i r s t message was immediate; Sandra acknowledged that crying was t i r i n g and decided to have a nap and j o i n the group. I f , on the other hand, the s t a f f had empathized and nurtured Sandra the result may be an encouragement of the depressive behavior by rewarding i t s expression. 129 Intervention #2 The second message was also delivered to Sandra while she was crying. The message was as follows: "Do you f i n d i t more or less helpful for your sadness to cry?" Sandra appeared confused when the message was delivered and f a i l e d to respond to the question. Analysis Again, t h i s question helps to frame the problematic behavior as purposeful and under Sandra's control. The message suggests that there may be other ways to deal with her sadness and that perhaps crying may not be h e l p f u l . Since the question i s an open one, the s t a f f i s able to remain neutral in r e l a t i o n to the symptom. The confusion that Sandra exhibited when hearing the message may be a sign that the message was e f f e c t i v e . As other c l i n i c i a n s have reported (Weeks and L'Abate, 1982; Watzlawick et a l . 1974), a confused response may be evidence that the c l i e n t i s beginning to view the symptoms from a new perspective. 130 Intervention #3 The t h i r d message was delivered as follows: "It's r e a l l y helpful for you to get in touch with your sadness. By crying and spending time in your room you are able to get i n touch with your f e e l i n g s . " Analysis This message i s a good example of p o s i t i v e l y connoting the symptom to reframe i t s meaning. The crying i s framed as a healthy response in the context of growth and r e h a b i l i t a t i o n . In t h i s example the s t a f f move from a neutral position to actu a l l y encouraging the presenting problem. The presenting problems which have become a concern, crying and i s o l a t i n g in her room, are s p e c i f i c a l l y mentioned i n th i s message. Sandra, indeed, began to spend a l o t less time in her room and her crying episodes decreased considerably after these messages were delivered. When talking to her approximately a year aft e r these messages were delivered, Sandra stated that af t e r coming to Vanhouse she began to f e e l much more in control of her own behavior. She stated, "I realized that I was the best person to help me". 131 Discussion These three messages were used in succession to consolidate a d i f f e r e n t perspective of the symptomatic behavior. The therapeutic goal was to reframe the "sick" behavior as a healthy response to legitimately d i f f i c u l t l i f e circumstances. In Sandra's case the depressive behavior may have served the function of drawing attention to her need for support and guidance. However her excessive crying and i s o l a t i o n had become more of a problem than a solution. By r e f r a i n i n g from empathizing with her depressive behavior and giving her "permission" to display i t , Sandra was l i k e l y freed up to try some new behavior as a solution to her problems. This case represents one of the most c l e a r l y successful interventions used at Vanhouse. Sandra's behavior changed dramatically within a short time period and her a f f e c t remained r e l a t i v e l y p o s i t i v e throughout her stay at the house. One factor that may have contributed to the success of t h i s intervention i s that Sandra was an introspective and curious adolescent. She was interested i n what the s t a f f had to say to her and listened to the delivered messages a t t e n t i v e l y and thoughtfully. 132 Case Example #3 - Lisa History and Presenting Problem Lisa was only 12 years old when she came to l i v e at the treatment home. Prior to placement she had been l i v i n g with her mother whose own behavior may be described as e r r a t i c and unreliable. Her father was l i v i n g in the U.S. with Lisa's older s i s t e r , where he had recently remarried. Although family therapy sessions were scheduled a number of times the parents f a i l e d to attend them. Lisa's father was s t r i c t with her, stating he would have l i t t l e to do with her u n t i l she "got better". Lisa was a very d i f f i c u l t person to engage. She ran away from the home regularly and would behave quite aggressively with s t a f f for no apparent reason. She seemed to have very l i t t l e trust for adults and was e a s i l y influenced by her peers. Intervention The s t a f f were of the opi acting out behavior was l i k e l y messages she was getting from he of view, i t was unclear whether nion that Lisa's unpredictable being f u e l l e d by the confusing r parents. From Lisa's point she would ever be returning to 133 l i v e with one of her parents. The more vague her parents were about Lisa's future the more desperate and disorganized her behavior became. The s t a f f formulated and delivered the following message: 1 > nWe understand from your behavior l a t e l y that you are f e e l i n g very confused about your family. 2 ' I n our experience confusion usually leads to growth. 3'So we expect i n the near future you w i l l start to f e e l less confused." Lisa's response was, "I'm going to stop doing drugs because they screw up my l i f e and I'm going to s t a r t school again on Monday and rest up and eat r i g h t " . Analysis ^-'This part of the message made an association between her behavior and the hypothesized confusion. The purpose here was to legitimize the disturbed behavior and at t r i b u t e i t to some concrete p r e c i p i t a t i n g factor. 2'The second part p o s i t i v e l y connoted the confusion by suggesting that something good would come from i t . 3'The l a s t sentence in the message suggested that the confusion was temporary and that she could expect some change in the near future. 134 Discussion The basic goal of t h i s intervention was to help Lisa make some sense of the chaotic s i t u a t i o n she was experiencing. The message was e s s e n t i a l l y an empathic intervention that acknowledged the confusion and anxiety present in her family s i t u a t i o n . The s t a f f were hoping that i f Lisa could a t t r i b u t e her e r r a t i c , irresponsible behavior to a legitimate p r e c i p i t a t i n g factor then she might f e e l a l i t t l e less out of control. From Lisa's i n i t i a l response one might assume that the message was pe r f e c t l y targeted and made a s i g n i f i c a n t impact. However Lisa's behavior continued to be inappropriate and throughout her stay at Vanhouse her behavior showed l i t t l e improvement. One possible explanation for the f a i l u r e of t h i s intervention may be due to the vagueness of the message. The message did not mention any s p e c i f i c behaviors but instead referred to the resident's general confusion. In addition the second sentence in the message states, "In our experience confusion usually leads to growth". A concept such as t h i s may be too sophisticated to make an impact on a 12 year old. To increase the impact of t h i s type of a message i t might be helpful to simplify i t and s p e c i f i c a l l y mention those behaviors which are targeted for change. 135 Weeks and L'Abate (1982) have observed that the most e f f e c t i v e paradoxical interventions are often met by the c l i e n t with a look of confusion or anger. Lisa's compliant response may be evidence that the message was not "powerful" enough to a l t e r her perception of the s i t u a t i o n she was experiencing. Case Example # 4 - Shannon History and Presenting Problem Shannon, at 18 years of age, was the eldest g i r l i n the home and had a great amount of influence on her peers' behavior. Prior to coming to Vanhouse she had spent more than a year i n another treatment f a c i l i t y . Her behavior was often quite c o n t r o l l i n g and manipulative and she had a knack for setting herself up in opposition to the s t a f f ' s requests and expectations. In the weekly discussions the s t a f f came to the conclusion that Shannon was quite p r o f i c i e n t at proving how much of a " f a i l u r e " she can be. She seemed determined to choose behavior that would get her in trouble and encouraged her peers to do the same. Information from family therapy sessions revealed that Shannon played a similar role in her family of o r i g i n . This role i s often c a l l e d the "black sheep", and in Shannon's 136 family her behavior contrasted sharply with that of her older, more responsible s i s t e r . Intervention In formulating an intervention the s t a f f thought i t might be helpful to draw attention to the role that Shannon played within her family and at the treatment home. The following message was delivered: "Why do you spend so much time and work so hard at trying to convince us what a fuck-up you are?" Shannon's i n i t i a l response was, "I'm not as fucked-up as I used to be i " Analysis There are a few things worth noting about t h i s intervention. F i r s t of a l l the message i m p l i c i t l y suggested that the problematic behavior was purposeful and under Shannon's contr o l . By framing the behavior in t h i s way, i t was hoped that Shannon would begin to question the motives for her behavior. She might even begin to put the pieces together and achieve some awareness of how the family system has influenced her behavior. 137 Secondly the message reframes the process by which the label of "fuck-up" has been attributed to Shannon. Presumably from Shannon's point of view i t i s others, s p e c i f i c a l l y adults, who have lab e l l e d her as the "black sheep". The message, however, suggests that the process has worked the other way around, with Shannon trying to prove to others that she i s a f a i l u r e . A d d i tionally, the use of the word "convince" i n the message suggests that the s t a f f do not consider Shannon to be a f a i l u r e . An important point should be made here in reference to the language used in t h i s message. When formulating messages i t i s essential that the language chosen makes sense to the resident. The term "fuck-up" was language that Shannon would use to describe someone who consistently misbehaved. Since the wording of the message i s c r u c i a l in determining i t s eventual impact on the resident, language that matches the world view of the recipient should be used. I f , for example, the message had stated; "why do you try so hard to convince us how much of a behavior problem you are?", then Shannon would most l i k e l y interpret the message as simply another rejection by adult authority figures. P a l a z z o l i et a l . (1978), and Weeks and L'Abate (1982) also stress the importance of using language that matches the c l i e n t ' s world view. 138 Again the most important aspect of t h i s message i s the way in which i t refrained Shannon's behavior as voluntary and purposeful with her working to "convince" the s t a f f that she was a f a i l u r e . Case Example #5 - Tina History and Presenting Problem Tina was f i r s t placed at Vanhouse in December of 1986. Prior to her a r r i v a l she had spent some time in a number of assessment and treatment f a c i l i t i e s . Tina's mother was described as a "highly v o l a t i l e " woman and her r e l a t i o n s h i p with Tina was up and down, with Tina returning home for b r i e f i n t e r v a l s before coming to Vanhouse. Tina's behavior was characterized as self-destructive and she displayed a low tolerance for f r u s t r a t i o n . She was often demanding and verbally aggressive with s t a f f . On a couple of occasions she had become ph y s i c a l l y aggressive with s t a f f . She was 14 years old when f i r s t placed at Vanhouse. Intervention When discussing Tina's behavior the s t a f f were struck by the "tough exterior" that she displayed. In family therapy 139 sessions i t was discovered that Tina's explosive mother also displayed a tough exterior. The s t a f f hypothesized that Tina's "toughness" served a s e l f - p r o t e c t i v e function, masking a vulnerable and sensitive side which she had d i f f i c u l t y exposing. The following intervention was delivered to reframe her behavior in a po s i t i v e l i g h t : "We have noticed that you act tough sometimes and we can understand i t because i t i s probably your way of dealing with the sadness that you have." Tina's i n i t i a l response was one of confusion and she asked for the message to be repeated. Analysis The basic goal of t h i s message i s to reframe the behavior so that Tina might achieve some insight into her c o n s t r i c t i n g "tough" behavior. The choice of the word "act" in the message suggests that Tina's behavior i s put on to achieve some e f f e c t . The message was made more powerful by t e l l i n g Tina that "we", the s t a f f , "have noticed", instead of stating that the observation was made by one person. 140 Discussion The message communicated to Tina that the s t a f f understood her need to protect herself from the pain in her l i f e . It i s quite common for adolescents who have spent time going from one resource to another and who have had stormy relationships with t h e i r parents to present a tough exterior and avoid establishing relationships with others. P o s i t i v e l y connoting t h i s protective function would hopefully free Tina up to t r y out some new, more rewarding behaviors. In the weeks that followed the delivery of t h i s message i t was observed that Tina seemed more at ease exposing her more sensitive side to others. On those occasions when Tina would act tough, s t a f f would casually mention her need to present herself that way and t h i s seemed to e f f e c t i v e l y defuse her aggressive behavior. In a l l of the above examples the symptomatic behavior i s reframed and in some cases prescribed. Reframing serves the function of a l t e r i n g the meaning of the symptom in order that behavioral change w i l l follow. Once the meaning of the symptom has been altered then i t no longer makes sense within the previously established context. For example, the adolescent who i s determined to oppose and rebel against those in 141 authority positions i s unlikely to do so i f the authority figures accept and even prescribe the oppositional behavior. On another level these interventions communicate to the resident that the s t a f f respects the resident's "need" to behave in whatever way they are behaving. If the resident i s accepted for who they presently "are", then hopefully they w i l l be able to further develop and experiment with new, more rewarding behaviors. An important element of the was the use of messages which re the residents both within the t r family system. By having acce from family therapy sessions, adequately equipped to formulat the residents' behavior withi environments. In the concludi to improve the effectiveness r e s i d e n t i a l treatment environmen interventions used at Vanhouse f l e e t the behavior exhibited by eatment home and within t h e i r ss to the information provided the s t a f f were more than e interventions that "captured" n the family and treatment ng chapter some thoughts on how of systemic work within the t w i l l be provided. 142 i CHAPTER 5 - DISCUSSION AND CONCLUSIONS The purpose of t h i s chapter i s to make some general statements of conclusion concerning the treatment approach that was introduced at the Vanhouse residence. These statements function to broaden the theory of a strategic/systemic approach to r e s i d e n t i a l treatment and hopefully w i l l guide future investigators and pr a c t i t i o n e r s in t h e i r work. The four issues, or "roadblocks" to e f f e c t i v e r e s i d e n t i a l treatment, which were i d e n t i f i e d in the introduction, provide us with an excellent theoretical backdrop on which to examine the r e l a t i v e success of the Vanhouse treatment approach. Success, here, i s measured against the theoreti c a l propositions suggested by the corresponding l i t e r a t u r e , and not by a quantitative analysis of behavioral change in the residents. Some suggestions for s p e c i f i c improvements and adjustments to a strategic/systemic approach to r e s i d e n t i a l treatment w i l l also be provided in t h i s chapter. The f i r s t t h e o r e t i c a l problem, which was i d e n t i f i e d i n the introductory chapter, concerns the "Identified Patient" concept. When the adolescent i s singled out as the problem and i s placed in care, there i s an i m p l i c i t message that the family problems can be resolved by curing the I.P. i n i s o l a t i o n from 143 the family u n i t . As was stated e a r l i e r , from a systemic perspective, the problem i s an i n t e r a c t i v e one, involving the whole family unit. Any attempt to treat the individual in i s o l a t i o n i s l i k e l y to be i n e f f e c t i v e and may even exacerbate the s i t u a t i o n . To address t h i s I.P. problem the Vanhouse approach included family therapy sessions as part of the program. The purpose of these sessions was to introduce change at the "family system" l e v e l . By e n l i s t i n g the support of the parents the s t a f f hoped to move the focus of the problem from the i d e n t i f i e d adolescent to the family as a dysfunctional u n i t . Unfortunately many of the residents' families f a i l e d to show up for t h e i r scheduled meetings. In some cases the resident's parents refused to cooperate with treatment u n t i l they were s a t i s f i e d that t h e i r daughter had shown some improvement i n her behaviour. Of course, without the family's involvement, the resident's view of herself as the cause of the problem i s consolidated and her behavior i s l i k e l y to continue to deteriorate. One possible strategy to increase the family's attendance record for therapy sessions would be to contract for a number of s p e c i f i e d sessions at the time of i n i t i a l placement. By stressing the importance of the family's p a r t i c i p a t i o n in the 144 treatment process and agreeing on, perhaps, ten sessions, a cooperative relationship would be established between the family and the treatment team. In an e f f o r t to counter the I.P. problem and to encourage the p a r t i c i p a t i o n of the family, Menses and Durrant (1987) stress the importance of framing placement as a p o s i t i v e step in the family's treatment process. They suggest that the r e s i d e n t i a l s t a f f frame the placement as a r i t e of passage, which marks the change of context to one i n which the family i s able to stand up to the problem together. The incorporation of treatment strategies, such as the above, may have contributed to a more p o s i t i v e working relationship between the s t a f f and the residents' families at Vanhouse. As i t was, the family's involvement in the treatment process was lacking somewhat and, as a r e s u l t , the perception of the resident as the " i d e n t i f i e d patient" was strengthened. The second "test" of the treatment approach, which was i d e n t i f i e d in the introduction, has to do with the surrogate parent issue. As was stated e a r l i e r , placement may exacerbate the "problem" by disturbing the natural process of separation and attachment that occurs during an adolescent's development. If the s t a f f take on a surrogate parent role, then they may act to block the interaction that would eventually occur between 145 the family and the adolescent. In other words, i f the s t a f f provide the adolescent's need for intimacy, then there i s less l i k e l i h o o d that the adolescent w i l l put in the required e f f o r t to resolve the family disturbance. As was described in the Results chapter, the s t a f f ' s f i r s t attempted solution for resolving the surrogate parent problem proved to be unsuccessful. This solution involved the s t a f f "backing o f f " from the development of close, dependent relationships with the residents and d i s c r e t e l y encouraging the residents' i n t e r a c t i o n with t h e i r family. It was hypothesized that t h i s strategic policy resulted in a "backlash e f f e c t " , where the residents reacted in an angry manner to the now more distant s t a f f . To counter t h i s "backlash e f f e c t " the s t a f f provided a rela t i o n s h i p which they f e l t was a compromise between t h e i r two previous positions. Ideally, the s t a f f hoped to provide a relationship which was r e l a t i v e l y supportive and engaging, while leaving the residents the necessary "space" to interact with t h e i r family. From both a p r a c t i c a l and t h e o r e t i c a l standpoint t h i s compromise position seems to be the most advantageous way to resolve t h i s s t a f f - r e s i d e n t r e l a t i o n s h i p issue. However, i t should be noted that each s t a f f member has t h e i r own individual way of interacting with residents and, as 146 a r e s u l t , i t can be d i f f i c u l t to establish a uniform approach to s t a f f - r e s i d e n t relationships. One recommendation i s to have the supervisor monitor staf f - r e s i d e n t relationships and intervene whenever he or she f e e l s that a s t a f f member i s behaving i n an overly engaging or overly distant manner with a resident. It i s important that the manner of i n t e r a c t i o n between s t a f f and resident f a l l within certain agreed-upon parameters in order to avoid problems such as c o a l i t i o n s , favoritism and scapegoating. Perry et a l . (1984) discuss the problems of triangulation that can occur between the adolescent, the s t a f f , and the adolescent's family. In t h e i r paper they i d e n t i f y a number of separation and attachment issues that can complicate the r e s i d e n t i a l treatment s i t u a t i o n . E s s e n t i a l l y , t h e i r primary concern i s the disempowering e f f e c t that r e s i d e n t i a l placement has on the i n t e g r i t y of the family u n i t . To minimize the counter-therapeutic aspects of treatment i n i s o l a t i o n from the family, they suggest the following: 1) the program should serve only as a catalyst to energize the relationship between the family and the resident. 2 ) the program should best r e f l e c t a quality of non-attached nurturance and unconditional family empowerment. 3 ) no matter what state the family relationship i s i n , the resident should be unconditionally 1 4 7 supported for having as much possible connection and support from family. 4 ) s t a f f ' s role should be to unrelentingly confront the family with t h e i r r e s p o n s i b i l i t y and value to the resident's well-being. 5 ) the family should be involved in the treatment plan and should be i n v i t e d to p a r t i c i p a t e in a c t i v i t i e s i n the house, as well as attend regular family therapy sessions. (pps. 2 3 - 2 4 ) These suggestions are, to a great extent, i n accordance with the strategic/systemic approach that developed at Vanhouse. However, in regards to supporting residents i n t h e i r i n t e r a c t i o n with family members, the Vanhouse s t a f f took a more neutral position than the one suggested by Perry et a l . ( 1 9 8 4 ) . At Vanhouse the policy was to neither encourage nor discourage family contact. It was thought that by remaining neutral the residents were best able to decide for themselves i f , and when, they were ready for family contact. In regards to family involvement in the treatment process, the residents' families at Vanhouse were not as.actively involved as Perry et a l . ( 1 9 8 4 ) recommended. On occasion the parents were consulted about minor treatment issues l i k e curfew times and clothing expenses, but, on the whole, they were minimally involved in the on-going process. From the author's point of view, as a participant observer, a more engaging and cooperative r e l a t i o n s h i p with the residents' parents would have l i k e l y increased the overall effectiveness of the approach. 148 The n e u t r a l , p a s s i v e r o l e that the Vanhouse s t a f f assumed may have been i n t e r p r e t e d by the parents as a message t h a t t h e i r p a r t i c i p a t i o n was not expected or d e s i r e d . The t h i r d i s s u e t h a t the Vanhouse s t a f f had to address i n v o l v e d the problem of c l i e n t r e s i s t a n c e to change or treatment. As was d e s c r i b e d i n the R e s u l t s chapter, r e s i s t a n c e was d e a l t with by 1) a v o i d i n g the assumption of an overpowering or h i g h l y d i r e c t i v e r o l e i n r e l a t i o n to the r e s i d e n t s , 2) a v o i d i n g the assumption of an "us and them" or a d v e r s a r i a l r o l e between the s t a f f and the r e s i d e n t s as a group, and 3) u s i n g s t r a t e g i c / s y s t e m i c i n t e r v e n t i o n s as the predominant treatment method. In r e f e r e n c e to the f i r s t method f o r d e a l i n g with r e s i s t a n c e , the s t a f f avoided t a k i n g on a h i g h l y d i r e c t i v e r o l e and communicated to the r e s i d e n t s t h a t they, themselves, were the o n l y ones who c o u l d decide what was best f o r them. By doing so the s t a f f were hoping to a v o i d the s i t u a t i o n where the a d o l e s c e n t f e e l s powerless and proceeds to oppose anyone i n a p o s i t i o n of a u t h o r i t y or g u a r d i a n s h i p . Underlying t h i s empowering s t r a t e g y was the b e l i e f t h a t the a d o l e s c e n t s would begin t o develop self-imposed l i m i t s on t h e i r i n a p p r o p r i a t e behaviour. In a study such as t h i s i t i s i m p o s s i b l e to determine c o n c l u s i v e l y whether t h i s dynamic a c t u a l l y o c c u r r e d . 149 From Redl's (1952) theoret i c a l standpoint, which i s described in d e t a i l in the Review chapter, i t i s questionable whether adolescents from dysfunctional families would have the necessary "ego strength" to self-impose l i m i t s on t h e i r inappropriate impulses. It i s possible that some of the residents' unpredictable, out-of-^control behavior could have been better managed, both in a p r a c t i c a l and therapeutic sense, by applying more d i r e c t i v e force. The author's opinion on the above issue i s that an empowering strategy can be a very e f f e c t i v e therapeutic tool i f used with adolescents who are developmentally ready to assume r e s p o n s i b i l i t y for t h e i r behavior. On the other hand, i f the s t a f f give up too much perceived control to a resident who i s not ready to receive i t , then they may act to increase the adolescent's out-of-control behavior. The s i t u a t i o n may be analogous to the "omnipotent c h i l d " dynamics, where the c h i l d presumably acts out as a means for probing the l i m i t s of his or her personal power. In the r e s i d e n t i a l setting, then, some adolescents may be too immature to benefit from messages that they, themselves, are the only ones who can decide what i s best for them. For these adolescents the imposition of l i m i t s from the "outside" may be necessary before any self-imposed l i m i t s are possible. 150 To make the above discussion more concrete, a couple of s p e c i f i c examples from Vanhouse may be h e l p f u l . The f i r s t example involves a 16 year old g i r l who presented with complaints of depression and problems associated with alcohol abuse. I n i t i a l l y she displayed highly dependent behavior with the s t a f f and tended to dramatize her "depressive" behavior. She was keen on r e l a t i n g her many, varied problems to s t a f f and a c t i v e l y sought others' advice. In response, the s t a f f consistently framed her "depression" as sadness and p o s i t i v e l y connoted i t s expression. In addition, the s t a f f repeatedly conveyed the message that she was the only one who could i n i t i a t e any changes in her behavior. E s s e n t i a l l y i t was communicated to her that she was the only one who had the power to l i m i t and a l t e r her own behavior. Over the next couple of months, i t was observed that the above resident's behavior improved s i g n i f i c a n t l y . She appeared less "depressed" and seemed to be imposing more appropriate l i m i t s on her previously e r r a t i c behavior. The message of empowerment appeared to be successful in as much as she was beginning to take r e s p o n s i b i l i t y for her own behavior. The second example involves a thirteen year old whose presenting problems included an explosive relationship with her mother and numerous "acting-out" incidents that may be 151 categorized as rebellious and immature. In keeping with the Vanhouse strategy of dealing with resistance and avoiding a power struggle, the s t a f f communicated to the resident that she was r e a l l y the only one who could e f f e c t i v e l y put l i m i t s on her own behavior. The s t a f f refrained from applying s t r i c t consequences to her inappropriate behavior and i n s i s t e d that the resident make her own "responsible" decisions. In t h i s case the "empowering" strategy seemed to backfire, as the resident's behavior became increasingly problematic throughout her placement. On a number of occasions she was verbally abusive with s t a f f members and her outbursts escalated to the point where she was physically s t r i k i n g out at the s t a f f . The difference in the two examples reported above may be attributed to the residents' respective maturity or developmental stage. In the f i r s t example, with the older adolescent who tended to look to others for guidance, the empowering message and the lack of s t r i c t controls served an appropriate function. She was at the developmental stage where guidance and l i m i t s imposed from the "outside" would have contributed to her dependent, "irresponsible" behavior. However, in the second example the message of "empowerment" and the assertion that the s t a f f were r e a l l y powerless to e f f e c t any behavioral change, l i k e l y exacerbated the 13 year old's f e e l i n g of being "out-of-control" and contributed to her need 152 to display reckless behavior. It might have been more ef f e c t i v e , with the more immature resident, for s t a f f to impose firm l i m i t s on her behavior u n t i l she was developmentally "ready" to impose her own l i m i t s . In conclusion, then, the strategy and messages communicated to each resident should be matched to the s p e c i f i c developmental stage that they have reached. A "blanket po l i c y " to deal with resistance and l i m i t setting i s not recommended when working with adolescents who are at various stages in t h e i r developmental maturity. In regards to the second method for dealing with c l i e n t resistance, that encountered when the residents band together and view the home as a s t a f f vs. residents s i t u a t i o n , there i s l i t t l e more to report. Strategies that avoided sanctioning the residents as a group seemed to adequately address t h i s potential problem. Group meetings also provided a good opportunity to discuss and defuse any growing feelings of h o s t i l i t y towards the s t a f f . The t h i r d method of dealing with resistance, the use of strategic/systemic interventions, w i l l be discussed i n d e t a i l shortly. The l a s t problem, or roadblock, associated with r e s i d e n t i a l treatment i s concerned with the necessity that s t a f f manage the inappropriate behavior of the residents. The issue that arises here i s to what extent the s t a f f ' s 153 therapeutic role i s jeopardized when they are required to assume a position of authority and control in the home. The solution to t h i s issue can be found i n the previous discussion. For those adolescents who are developmentally at a stage where they are ready to impose t h e i r own l i m i t s and take on more r e s p o n s i b i l i t y , the s t a f f ' s most advantageous therapeutic role i s to back-off from the authoritative stance. For those adolescents who have not yet reached the developmental stage where they can assume r e s p o n s i b i l i t y for t h e i r own behavior, the s t a f f ' s therapeutic role necessarily involves assuming an authoritative stance. In other words, for adolescents who are developmentally immature when i t comes to s e l f - c o n t r o l , the s t a f f ' s therapeutic role i s not jeopardized by assuming an authoritative stance. On the contrary, i t i s suggested that for the immature adolescent, the s t a f f ' s most therapeutic strategy i s to provide the resident with a firm, c l e a r l y defined authoritative r e l a t i o n s h i p . The most unique, and i n many ways the most important, element of the Vanhouse approach were the strategic/systemic interventions or messages. These messages were "targeted" at s p e c i f i c behaviors of the residents and, in most cases, functioned to reframe the maladaptive behavior. From the various interventions u t i l i z e d at Vanhouse, p o s i t i v e connotation and prescribing the symptom seemed to be the most 154 e f f e c t i v e . This conclusion i s based simply on the observed responses of the residents and the opinions held by the s t a f f members. Positive connotation appeared to be an e f f e c t i v e way of "joining" with the resident. By accepting that the problematic behavior served some posit i v e function for the resident, the st a f f were able to assume a role that distinguished them from the t y p i c a l authority figure. In some cases, however, the residents continued to be antagonistic and oppositional with the s t a f f , and escalated t h e i r provocative behavior as an i n v i t a t i o n for contro l . One controversial issue that arose concerning the use of positi v e connotation, centers on the question of whether t h i s type of message can be misinterpreted. Positive connotation acts both to; 1) reframe the meaning of the behavior, and 2) place the s t a f f i n a neutral, or "positive" p o s i t i o n , in re l a t i o n to the symptomatic behavior. Although the e x p l i c i t message of the intervention p o s i t i v e l y reframes the symptomatic behavior, the overall goal of the intervention i s , obviously, to l i m i t the expression of that behavior. In some cases the resident can e a s i l y perceive both the posit i v e and negative aspects of an i d e n t i f i e d behavior. For example, i f the s t a f f t e l l a resident that crying alone in her room i s a good thing, 155 then the negative aspects of the p o s i t i v e l y connoted behavior would most l i k e l y be evident to the resident. In other words, although she may begin to see that the behavior may have a pos i t i v e function, she also must f e e l that she does not want to cry for too much longer. In other cases the negative aspects of some i d e n t i f i e d presenting problem may not be as evident to the resident. For example, i f a resident i s staying out late past her curfew repeatedly, she may not perceive any drawbacks to t h i s behavior when i t i s p o s i t i v e l y connoted. In t h i s case, posit i v e connotation would not function to reframe the meaning of the behavior. If the behavior in question has not been reframed for the resident, due to the fact that the resident cannot perceive any negative aspects to i t , then posi t i v e connotation may exacerbate the problem by actually increasing the expression of the symptom. To avoid t h i s problem, a message of po s i t i v e connotation can be formulated i n such a way that the negative consequences of the behavior are also spelled out by the s t a f f . For example, the message might go as follows: "The s t a f f have noticed how d i f f i c u l t i t i s for you l a t e l y to return on time for curfew. We understand that you are making friends out there and we think that's great. However you are having trouble getting up in the morning and your school work i s probably suffering from lack of sleep. Do you think you can s t i l l see your friends and make i t in for curfew?" 156 This type of message p o s i t i v e l y connotes the intention of the behavior, making friends, while pointing out some of the negative consequences of staying out too l a t e . In conclusion, then, for c e r t a i n behaviors, where the negative aspects of the behavior are not self-evident to the resident, the message should contain both the p o s i t i v e and negative consequences of the i d e n t i f i e d behavior. Another intervention at Vanhouse which appeared quite promising was "prescribing the symptom". When a symptom was prescribed the resident was encouraged by the s t a f f to display some behavior which would usually be considered undesirable. Some examples of behaviors that were prescribed include; depression, f r u s t r a t i o n , anxiety, anger and sleeping d i f f i c u l t i e s . Theoretically, once the behavior i s prescribed, the resident should have d i f f i c u l t y spontaneously expressing i t . Prescribing the symptom suggests that, to some extent, the behavior i s under voluntary c o n t r o l . One of the common reasons for prescribing the symptom at Vanhouse was to provide the residents with an acceptable explanation for t h e i r dysfunctional behavior. The Vanhouse s t a f f were of the opinion that although the residents regularly defended and denied that t h e i r behavior was a cause for concern, they were inwardly confused and disturbed by t h e i r own 157 actions. The s t a f f hoped that by a t t r i b u t i n g a benign motive to the inappropriate behavior, the resident would begin to f e e l more at ease and less g u i l t - r i d d e n . For example, a resident might be directed to continue arguing with s t a f f because t h i s would help to rel i e v e some of the tensions coming from her unresolved family s i t u a t i o n . As we can see, the motive attributed to the behavior i s an acceptable one; anxiety, and the resident i s given permission to express i t . The goal, of course, i s that once the resident has been given permission to display the behavior, and the behavior has been attributed a benign motive, the resident w i l l f e e l less compelled to display that behavior. Aside from the question of how or why the interventions used at Vanhouse were e f f e c t i v e , more often than not, the messages appeared to have a p o s i t i v e therapeutic impact. In those cases where the messages seemed to have l i t t l e or no e f f e c t , i t may be hypothesized that the following elements were lacking; 1) the message was not matched with the developmental level of the resident. 2) the way in which the message was delivered underscored i t s impact, i . e . a more "formal" presentation may have been more e f f e c t i v e . 3 ) the language used i n the message did not "match" the resident to whom i t was being delivered, i . e . the s p e c i f i c words chosen were not suited to the adolescent's world view. 158 4 ) and, f i n a l l y , the s p e c i f i c strategy chosen was off "target", i . e . the message f a i l e d to capture the s i g n i f i c a n t dynamics of the s i t u a t i o n . Another important concept related to formulating interventions has been described by Bergman (1980). Bergman suggests that symptoms displayed by residents serve some function for them and are maintained by the emotional system within the community home. He also introduces the concept of "context r e p l i c a t i o n " , suggesting that the symptoms that the resident displays i n the treatment home may have served a si m i l a r function when the resident was l i v i n g with his or her family of o r i g i n . Observations at Vanhouse d e f i n i t e l y support the hypothesis that symptomatic behaviors which originated in the family context, are "reenacted", in one form or another, i n the r e s i d e n t i a l setting. It i s suggested further, by the present author, that these "reenacted" behaviors should be the primary "target" for strategic/systemic interventions. The reason why these "reenacted" behaviors are of c r i t i c a l importance has to do with the fundamental treatment goal. This goal i s to a l t e r the dysfunctional behavior of the resident's family as a unit, in order that the resident may eventually return to that family. Those behaviors which are replicated i n the treatment context are manifestations of the family dysfunction. By focusing on these behaviors, the resident's return, and ultimate successful functioning, within the family unit i s f a c i l i t a t e d . i In order to formulate successful interventions; those that target "reenacted" behaviors, i t i s essential that the s t a f f have a good knowledge of the family history and dynamics. This knowledge comes from the previous written h i s t o r i e s on the families and the information gathered by the family workers. For t h i s reason, good communication between the family workers and the rest of the treatment s t a f f i s a necessity. It i s suggested that to enhance t h i s communication the c h i l d care workers should be involved, somehow, in the family therapy sessions: preferably as observers behind a one-way mirror. In addition, the family workers would benefit from day to day observations of the residents in the treatment context. By overlapping the functions of the c h i l d care workers and the family workers a more complete picture of the individual and family dynamics w i l l be attained, and, consequently, more successful interventions should follow. F i n a l l y , some general s strengths and weaknesses of r e s i d e n t i a l treatment can be treatment approaches described Vanhouse approach squarely ad tatements about the r e l a t i v e the Vanhouse approach to made. Unlike many of the in the Review chapter, the dresses the problems associated 160 with treating an individual in i s o l a t i o n from the family unit. Both the relationship of the s t a f f to the residents and the interventions u t i l i z e d , sought to avoid disempowering the family unit. Also, by avoiding the assumption of an overly c o n t r o l l i n g and d i r e c t i v e relationship with the residents the s t a f f f a c i l i t a t e d the natural process of developmental maturity. Some r e s i d e n t i a l programs are highly d i r e c t i v e and apply severe consequences as a means of teaching the residents "appropriate" behavior. The Vanhouse s t a f f questioned whether behavior "learnt" under these circumstances i s transferrable once the resident returns home. By "empowering" the resident to make her own decisions, and giving her room to make her own mistakes, the Vanhouse s t a f f hoped to provide more long-l a s t i n g , transferrable behavioral change. One of the contraindications inherent in using strategic/systemic methods in the r e s i d e n t i a l setting has already been i d e n t i f i e d . This problem arose when immature adolescents escalated t h e i r provocative behavior, presumably, as a r e s u l t of a lack of s t a f f control and d i s c i p l i n e . Immature adolescents, who are not ready to assume r e s p o n s i b i l i t y for t h e i r behavior, may require more pronounced control and d i s c i p l i n e before they are ready to receive l e s s . Another problem that was encountered at Vanhouse involved the s t a f f members' attitude toward the approach. Some of the 161 workers questioned whether the new changes to the program would be e f f e c t i v e and, as a re s u l t , t h e i r support was lacking. Needless to say, without f u l l support from the s t a f f , the treatment approach suffered and the residents became aware of a lack of enthusiasm on the s t a f f ' s part. This kind of issue i s best dealt with by holding meetings and resolving any differences between the s t a f f members. In reference to the t r a d i t i o n a l theories of r e s i d e n t i a l treatment described i n the Literature Review chapter, some comparisons and contrasting issues are noteworthy. As with both the psychoanalytic and behavioral approaches, the Vanhouse approach acknowledged the importance of the " t o t a l treatment environment". The rules, routines, a c t i v i t i e s , s t a f f / c h i l d interactions and architecture of the treatment environment were a l l taken into account as important ingredients of the treatment approach. It may be said that the Vanhouse treatment approach emphasized the importance of the front l i n e worker, or c h i l d care worker, to a greater extent than any of the t r a d i t i o n a l approaches to r e s i d e n t i a l treatment. By incorporating strategic/systemic interventions into t h e i r day to day contact with residents the s t a f f hoped to encourage behavioral change at the staf f / r e s i d e n t i n t e r a c t i o n a l l e v e l . 162 B e h a v i o r a l change was a l s o encouraged at the f a m i l y system l e v e l by p r o v i d i n g f a m i l y therapy s e s s i o n s . In order to a v o i d a s e p a r a t i o n between the f a m i l y therapy and the on-going c h i l d care work, the f a m i l y t h e r a p i s t s p a r t i c i p a t e d i n the weekly s t a f f meetings. U n l i k e the t r a d i t i o n a l approaches d e s c r i b e d e a r l i e r , the Vanhouse approach u n d e r l i n e d the importance of us i n g i n f o r m a t i o n from f a m i l y therapy s e s s i o n s i n the f o r m u l a t i o n and d e l i v e r y of r e s i d e n t i a l treatment i n t e r v e n t i o n s . The i n c o r p o r a t i o n of f a m i l y therapy, and the use of i n f o r m a t i o n from f a m i l y therapy s e s s i o n s i n the on-going treatment, are two aspects of the Vanhouse approach which c l e a r l y d i s t i n g u i s h i t from the t r a d i t i o n a l r e s i d e n t i a l treatment approaches. As has been s t a t e d p r e v i o u s l y , most r e s i d e n t i a l treatment p h i l o s o p h i e s suggest t h a t a n u r t u r i n g , s u p p o r t i v e r e l a t i o n s h i p i s a key i n g r e d i e n t of t h e r a p e u t i c success (Bettelheim, 1974; Jones, 1980; Brendtro & Ness, 1983). A b e h a v i o r a l approach to r e s i d e n t i a l treatment concluded, upon attempting a r e p l i c a t i o n of a b e h a v i o r a l treatment home, th a t t h e i r system c o u l d o n l y work i n the context of a warm, open and g i v i n g i n t e r a c t i o n between s t a f f and r e s i d e n t s ( P h i l l i p s et a l . , 1973a). The s t a f f at Vanhouse a l s o concluded t h a t t h e i r approach was v i a b l e only i f they p r o v i d e d a r e l a t i v e l y engaging r e l a t i o n s h i p with the r e s i d e n t s . However, the Vanhouse approach suggests t h a t 163 t h i s c r u c i a l r elationship should be less intimate and involved than the relationship that may develop in some of the t r a d i t i o n a l approaches to r e s i d e n t i a l treatment. The policy that the Vanhouse approach held in r e l a t i o n to "symptom tolerance" also distinguishes i t from many of the t r a d i t i o n a l approaches. Many of the symptoms that the residents displayed at Vanhouse were tolerated and allowed to come out in the open. There were two s i g n i f i c a n t reasons for t o l e r a t i n g symptom expression; 1) by presenting a tolerant atmosphere the s t a f f were able to more accurately assess the "true" behavior of the residents, and 2) with the symptoms out in the open the s t a f f were in a better position to manipulate them for treatment purposes; i . e . , once a symptom has been displayed the s t a f f are in a position to p o s i t i v e l y connote or prescribe i t . Some treatment approaches attempt to a l t e r behavior by applying s t r i c t consequences to inappropriate behavior and by providing the residents with a structural program. • The Vanhouse s t a f f were of the opinion that excessive " a r t i f i c i a l " , s t a f f induced constraints and l i m i t a t i o n s f a i l to encourage any long-lasting behavioral change. 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