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Family diagnosis and treatment in a children's psychiatric clinic: an assessment of the case-work focus… Peterson, Joan 1962

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FAMILY DIAGNOSIS AND TREATMENT IN A CHILDREN'S PSYCHIATRIC CLINIC An Assessment of the Casework Focus from the Recording. by JOAN PETERSON Thesis Submitted in Part ia l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL "WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1962 The University of Br i t i sh Columbia In presenting this thesis in p a r t i a l fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia, Vancouver 8, Canada. Date ABSTRACT There have been many changes in the focus and direction of social casework since Mary Richmond published Social Diagnosis in 1917. Casework in her day emphasized the socio-economic aspects of the family's adaptation to society. With the advent of psychoanalytical concepts, the focus shifted from the family's social reality to the individual's subjective response to i t , as one way of understanding the client's maladjustment to his l i f e circum-stances. In agencies and c l i n i c s , office interviews, with individuals replaced home visits to the family. Conse-quently, the caseworker's knowledge of the day-to-day social functioning of the client and his family was often incomplete. Caseworkers and psychiatrists in Child Guidance Clinics learned that the child could not be helped with his emotional d i f f i c u l t i e s unless the parents were included in the treatment process, since the child's maladjustment so frequently stems from unhealthy relationships with his parents. While the focus was upon the child and his family, the emotional aspect of each parent's adaptation was empha-sized. The interplay between family members' personalities and the problems for which they were seeking help was s t i l l too complex for f u l l understanding. The search for helpful concepts i s s t i l l in process. Current casework emphasis on the client's social functioning is attempting to integrate psychological and social concepts in casework theory. Role theory, combined with psychological concepts, holds the promise of providing a method by which the caseworker can diagnose and treat the problematic aspects of the individual's and family's adapt-ation. In order to understand the individual, i t is necessary to know how he interacts with family members, they with him, and his group with society at large. This study is an exploratory assessment, from casework recording alone, of the extent to which psycho-social diagnosis and treatment has been adapted to case-work practice for families with disturbed children in the Children's Clinic of the B.C. Mental Health Centre. Twenty cases of disturbed children were selected: between the ages of five and ten years l i v i n g with their own parents; capable of attending public schools; and not suffering from physical handicaps. Most of the children had siblings. They were active cases in which treatment had proceeded a substantial distance. Two rating scales were: (a) the xV child's emotional and s o c i a l adjustment and (b) parental and family relationships and strengths. These pointed up the areas of information obtained by the caseworker for the psychosocial diagnosis of the child's family, and also made i t possible to compare the child's adap-ta t i o n with that of his family's. The evidence i s that the s o c i a l functioning of the family as a unit is not apparent from the recording, that most emphasis i s upon the mother-child r e l a t i o n s h i p , and that the child's relationships with other family members are not s u f f i c i e n t l y explored. The Casework c o n t r i -butions to the diagnostic study of the child's problems are l a r g e l y i n the area of the parents' ( p a r t i c u l a r l y the mother's) emotional adjustment, and the child's p a r t i c u l a r development. The o r i g i n a l intention was to measure the child's and parents' s o c i a l functioning between two points i n the treatment process, but the recorded data was i n s u f f i c i e n t for t h i s purpose. Only descriptive comparisons are possible, also a descriptive evaluation of the outcome of treatment i n r e l a t i o n to the casework focus. The recording which described the greatest improvements in family r e l a t i o n s h i p s , and i n the parents' and c h i l d ' s s o c i a l functioning, was oriented, i n the treatment phase, to the c l i e n t i n his family, even though t h i s focus was not evident i n the diag-nostic study. Those cases which showed the least movement emphasized the emotional adjustment of i n d i v i d u a l members of the family. The main reference point in the former cases was the c l i e n t ' s i n t e r a c t i o n with people and situations i n his current l i f e circumstances; i n the l a t t e r cases, the worker's e f f o r t s were directed towards helping the c l i e n t with his emotional c o n f l i c t s , which stemmed from his early l i f e experiences. This i s an exploratory study of areas highly s i g n i -f i c a n t for family casework in the Children's C l i n i c . Although the conclusions require repeated research to v e r i f y t h e i r v a l i d i t y , they nevertheless suggest that a casework focus on the c l i e n t i n his family holds more promise of helping than a focus which emphasizes the c l i e n t ' s emotional adjustment alone. Such an orientation contributes to the d e f i n i t i o n of the casework function, and distinguishes the caseworker's r o l e from that of the p s y c h i a t r i s t . I t has contributions to make also, i n the task of integrating theory and practice in family casework. vi ACKNOWLEDGMENTS I wish to express my sincere gratitude to Dr. Leonard Marsh, Director of Research of the School of Social Work, for his steadfast encouragement, patience and assistance throughout the writing of this thesis . I wish also acknowledge the help of Mr. Donald Ricketts, Director of Social Services, Mental Health Centre, for his co-operation in providing the case record material, for the time which he contributed to this study, and for his guidance through the complexities of casework theory. i i TABLE OF CONTENTS Page Chapter 1. Family Casework and i t s Application  to Child Guidance Practice The current trends in soc ia l casework -family casework. Casework practice in a psychiatric c l i n i c ; definition of the casework function. Role differentiation between psychiatry and casework. Some psychiatric contributions to family therapy. Focus of study; Is casework in the Children's C l i n i c individual- or family-centred? Concepts for family casework: role theory; ego psychology. Related social work studies: the St. Paul Project; Current theses in casework measurement. Methodology.... 1 Chapter 2. Client and Family Assessment in  Diagnosis Symptoms of emotional disturbance in children; symptoms in the sample group. Socio-economic factors in sample cases. Families* relationships with their communities. Inter-relationships within families in the sample group; reciprocal parent-child relationships. Nuclear family relationships with the extended family. Family so l idar i ty . Comparison of chi ld 's treata-b i l i t y with impairment in the parent-child relat ion-ship. Individual or family focus? 46 Chapter 3. Family Assessment in Treatment The diagnostic conference; c l i n i c a l assess-ments of the sample cases. Six points which emerge from analysis of treatment focus. (1) Cr i ter ia to determine treatment goals, (2) Recording of treat-ment goals} caseworkers and parents, (3) Cr i ter ia for assignment of shared and unit cases, (4) Indi-vidual , joint and family interviewing methods in the treatment phase, (5) Involvement of family members in the treatment process, (6) Assessment of treatment. Conclusions: strengths and weak-nesses in the casework focus 80 Chapter 4. Improving: the Family Focus The community's awareness of the prob-lem of disturbed families; the C l i n i c ' s role in the community. Research and practice in i i i TABLE OF CONTENTS (continued) Chapter k (continued) Page family diagnosis and treatment - contributions from social work. Findings from sample case records. Recommended changes i n : the socia l history format; recording policy and practice. Other ways to improve recording practices: the "Varwig-McCallum" approaches. Conclusions on the effectiveness of family casework. Continuing needs: casework focus; recording methods; professional research 129 Appendices: A. Child's Schedule B. Parents' and family Schedule. C. Social History Outline D. Progress Conference Format E . Closing Summary F. Bibliography. Chapter 1, FAMILY CASEWORK AMD ITS APPLICATION  TO CHILD GUIDANCE PRACTICE Current Trends in Social Casework: The history of socia l casework reveals a changing emphasis from a primarily socio-environmental approach to individual and family problems prior to World War I to a "bio^psychic" model of personality in the th i r t i e s based on psychoanalytic concepts which stressed understanding the individual 's intra-psychic conflicts in relat ion to the prob-lems for which he was seeking help. During this period, inner and outer stresses were clearly separated. "By 1940, however, caseworkers were beginning to express their concern that focusing on the emotional condition of the individual had resulted in subordinating and neutralizing their under-standing of socia l f a c t o r s . D u r i n g the last twenty years the dichotomy between social and psychological components, although recognized as impeding effective casework practice, has persisted, and casework theory is said to have made only small advances in resolving this problem. From a review of the l i terature and from observation of casework practice, Dr. Sherman observes that a gap exists between theory which 1 Sherman, S.N. "The Concept of the Family in Casework Theory", Exploring the Base for Family Therapy. F . S . A . A . , New York, 1961, p. 15. 2 I b i d . , p. 16. 2 emphasizes psycho-social integration and "actual practice of analyzes, diagnosis and treatment of specific cases which deals almost exclusively with emotional aspects of personality and personality maladjustment.""^ Dr.Nathan Ackerman states: "The h i s tor ica l focus on the individual has brought a wealth of knowledge of internal mental processes but i t has imposed a blindness as to the urgency of evaluating i l lness as a family  process as wel l . Cr i ter ia for emotional i l lness and health cannot be restricted to the individual ; they must encompass the individual within the group and the group as wel l . The i l l s of the individual , the family and society are a continuum." 2 He goes on to suggest that "our conspicuous fai lure so far to prevent mental i l lness derives from our fai lure to cope with the mental health problems of family life."3 Professionals in the mental health f i e ld are turn-ing to this same point again and again - that the individual 's adjustment has been considered in terms of his own intra-psychic conflicts without sufficient recognition to the health and the pathology of the primary group in which he l ive s . Although this trend is being recognized and influenced 1 Sherman, Exploring; the Base for Family Therapy, p. 17« 2 Ackerman, N. W. Psychodynamics of Family L i f e , Basic Books Inc . , 1961, p. 7 (underlining added). 3 I b i d . , p. 9. 3 by psychiatry, the social work profession has been t rad i -t ional ly concerned with helping families towards healthier levels of functioning, and i t is in this area that the training and experience of socia l workers enables them to function. Casework Practice in a Psychiatric Setting How is this trend towards family therapy i n f l u -encing social work in a psychiatric setting, such as Child Guidance Clinics? For many years, i t has been recognized in Child Guidance Cl inics in North America that treating the emotion-a l ly disturbed chi ld in isolation from his family is not an effective method, Jackson & Satir write: "The Child Guidance Movement, which was i n i t i a l l y developed through the efforts of the Juvenile Court to treat delinquent N children spec i f ica l ly , rather naturally expanded to look for and include expe-ditious and economical means of diagnosing and treating neurotic and psychotic children. Experience, especially on the part of socia l workers, has led to the conclusion that treating the child is not enough and, more recently, that treating -i the child and the mother may not be enough." In many Child Guidance Clinics in North America i t became tradit ional to include the mother, with an ever 1 Jackson, D.D. , and Sat ir , V . " A Review of Psychiatric Developments in Family Diagnosis and Family Therapy", Exploring the Base for Family Therapy. F . S . A . A . , New York, 1 9 6 1 , p. 3 2 . 4 widening recognition since the 1 9 4 0 " s of the need to involve the father in treatment; recently, more attention is being given to the wisdom of including other significant persons in the family, such as s ibl ings , l i v ing- in relatives and members of the extended family. Despite the fact that the family milieu is seen as the focal point in understanding and treating the ch i ld , individual diagnosis and treatment is a better developed c l i n i c a l entity than family diagnosis, with the result that, although the main figures in a family may be involved in treatment, they may be viewed by social workers as individuals against the back-drop of the family rather than as active members of the group whose social adaptation influences and is influenced by other family members in a dynamic, ever-changing way. Dr. Sherman writes: "Changing from family-oriented to family diagnosis and treatment is more than an increase in intensity of the same approach. It represents a shift to viewing the dis-tress of the individual as less the prob-/ lem than a symptom of the problem of  pathology in the whole family^ Family Diagnosis is oriented to the cl ient in the family and their reciprocal interplay; i t replaces the separatism expressed in the phrase "the cl ient and his f a m i l y " . . . . The " i n " orientation is h o l i s t i c ; the "and" orientation is atomistic. These differing orientations reflect differences not only in personality theory but also in practical family analysis. One approach is to compre-hend and analyze the whole (the family) as a necessary concurrent condition to under-standing or analyzing the part (the individual) ; 5 the other approach defines components (individuals) and attempts to compre-hend the whole (the family) by inter-relation and synthesis . . . The ho l i s t i c orientation i s harmonious with socia l work tradit ion."1 Casework has been t radi t ional ly concerned with the relationship of the cl ient to the significant people and to the socia l institutions in his environment. A popular and widely accepted definit ion of casework today is offered by Helen Perlman. She writes: "Casework is a process, used by certain human welfare agencies, to help individuals to cope more effectively with their problems in socia l functioning." She describes socia l functioning as "an individual 's person-to-person, person-to-group, person-to-situation, transactions."^ It is therefore not only the c l ient ' s emotional adjustment that is the province of social casework, but the problematic ways in which his psychological, physical and social self affects, and is affected by, persons and situations in his environment. In Child Guidance C l in i c s , the most frequent problem which underlies the chi ld ' s symptoms is found in the parent-child relationship, par t i -1 Sherman, Exploring the Base for Family Therapy, p. 18. 2 Perlman, H.H. Social Casework, University of Chicago Press, Chicago, 111., 1957. 3 Perlman, H.H. "The Role Concept in Social Casework", Social Service Review. D e c , 1961, Vo l . 35, No. 4, Univ. of Chicago Press, Chicago, 111. 6 cularly the mother-child pa ir . What is happening in other family relationships, however, such as marital and s ib l ing inter-action, may have marked effects on the mother's and chi ld 's responses to each other. In addition, significant relationships and situations outside the family may contri-bute to impairment in family relationships and to the chi ld ' s disturbance. Diagnosis and treatment of the psycho-log ica l , physical, and social factors which contribute to dysfunctioning in parent-child relationships is therefore an appropriate casework focus in Child Guidance C l i n i c s . The central referance point is located in the caseworker's goal to enable parents and chi ld to achieve more satisfying ways of adapting to each other. This orientation is not intended to suggest that the profession abandon individual diagnosis and treatment in a c l i n i c a l setting, but rather that the psychosocial implications of family group l i f e be understood in as com-plete a way as possible, and ut i l i zed in the treatment of family members to help them improve their relationships with each other, particularly with the disturbed chi ld . This approach is oriented to the child in his family. However, i f the gap between psychosocial theory and practice exists in social agencies, which means that the interaction between the cl ient and his family is not 7 understood and treated, i t is very l i k e l y more evident in psychiatric c l i n i c s . In these settings, psychoanalytic concepts and methods, which stress emotional factors in the individual 's adjustment, may be expected to exert an even greater influence on social casework. This may mean that the chi ld 's and parents' relationship d i f f i cu l t i e s are viewed only in terms of each member's individual emotional confl icts , without sufficient knowledge of the impact of their relationships, and their current l i f e ex-periences, upon each other. Not only the problems, but the resources of the family group may be overlooked by the caseworker. Furthermore, i f the caseworker concentrates on the c l ient ' s personality dynamics, role confusion between the social worker's and the psychiatrist 's function ensues, which creates d i f f i cu l t ie s in team work and in the appropriate assignment of cases. Differentiation Between Psychiatry and Casework It has often been observed by psychiatrists and social workers that the function and goals of these two disciplines tend to merge in a psychiatric setting. Social work has gained considerable knowledge from psychiatry of personality dynamics and of techniques in working with dis-turbed individuals; many psychiatrists have, in turn, ex-tended their sphere of interest "into the realm of group behaviour, social patterns, and social pathology." 1 \ 1 H a m i l t o n , Gordon, Psychotherapy in Child Guidance. Columbia University Press, New York, 1 9 4 8 . P. v i i in the Forward by Dr. N. Ackerman. 8 Some overlapping of the functions of these two professions is therefore to be expected, and social workers and psychi-atrists often treat the same kinds of problems. Luc i l le Austin states that the aims and methods of the two disciplines are, however, quite distinct,"1" It is one of the arguments of this thesis that some differentiation of these roles is essential i f caseworkers are to become more certain of their function in a psychiatric setting. p Dr. Coleman states that differentiation of the psychiatrist ' s and caseworker's function becomes extremely d i f f i cu l t when the two professions are working together. He believes that their functions can and do overlap in some areas, but he maintains that their methods and goals must be essentially d i s t inct . In his view, the caseworker does not define the problem in terms of the clientIs intrapsychic confl ict ; rather, i t is the problem of a cl ient in relation to a distressing s ituation. The caseworker deals with people's feelings, with the impact of personality on the situation, and in the area of the relation of a person to a situation of distress. She reduces anxiety by understanding the c l ient ' s distress, and by relating" i t to i t s situational 1 Austin, L u c i l l e , "The Relationship between Family Agencies and Mental Health C l i n i c s " , Journal of Social Casework. Vo l . 3 6 , No. 2 , F . S . A . A . , New York. 2 Coleman, J .V. "Distinguishing between Psychiatry and Casework", Journal of Social Casework. V o l . 3 0 , No. 6 , F . S . A . A . , New York, 9 source. She strengthens the c l ient ' s defenses by support-ing even his rationalizations when they do not conflict with the immediate rea l i ty issues. She does not attack defenses but supports neurotic equilibrium. The case-worker's tools are " identi f icat ion of feeling as related to current problems, s i tuational c l a r i f i ca t ion , and the sharing of plans and, i f necessary, the burden of decisions with his clients,""'" The goal of casework is "to help the cl ient with his s ituational problems, and not to modify the cl ient Is character attitudes or his neurotic adaptations, although , such changes do occur almost as a by-product of the casework 2 process." Psychotherapy, on the other hand, "makes use of a patient's situational stress for an understanding of the disturbance of the dynamic equilibrium which has been preci-3 pitated by the new s i tuat ion." The goal of psychotherapy is to gradually undermine neurotic defenses so that they may be replaced by more spontaneous and more r e a l i s t i c attitudes. The psychiatrist i s not so concerned about an individual 's particular social situation as he i s about the pathological personality trends which emerge in the patient's response to that s i tuation. 1 Coleman, Journal of Social Casework, p. 247. 2 I b i d . , p. 246*. 3 I b id . , p. 249. 10 According to this view, the basic difference in function between the psychiatrist and the social worker emerges in the selection of the problem focus, in the establishment of goals, and in the methods used to achieve them. The social worker is concerned with the person in his s i tuation, and attempts to help the cl ient achieve more harmonious relations between himself and the particular problem which he brings to the agency. The psychiatrist , on the other hand, is more concerned with the individual 's personality structure, and attempts to enable the patient to modify and change pathological elements of his personality. Insight is a method which is u t i l i zed by both professions, but each in i t s own unique way; casework uses insight to obtain the co-operation of the conscious ego in dealing with situational problems; psychotherapy uses i t as an aid in the process of dealing with the patient's intrapsychic confl icts . S imilar ly , transference phenomena are recognized by both professions, but the "caseworker works within the transference, and the therapist works with the transference. The caseworker, recognizing transference impulses, moves to replace them with feelings related to the current situation, while the therapist attempts to provide some re l iv ing and working through of these impulses."-*-1 Coleman, Journal of Social Casework, p. 246. 11 Helen Perlman enlarges and makes more specific the term "s i tuation" so that the relationship of the client with his particular environment is understood as a two-way, interacting process. In her view, the problematic aspects of the c l ient ' s interaction with his environment is the appropriate casework focus. She writes: "The problems within the purview of social casework are those which v i t a l l y affect or are affected by, a person's social functioning The importance of the caseworker's orientation to the c l ient ' s problem as lying in his i n -ab i l i ty to function sat i s factor i ly in one or more of his major roles, or in his inab i l i ty to meet the deprivations and assaults of his life-circumstances, i s that i t helps the caseworker chart his focus, his work plan, and his goals. It means that he w i l l constantly keep before him the need to enable his client to cope with the frustrations and gain the potential gratifications in his every-day l i v i n g . And, since this l i v i n g takes place in dynamic interaction with other persons, social circumstances. cultural ly determined expectations and permissions, the caseworker w i l l take f u l l measure of these forces in each case in order to know how they need to be influenced and u t i l i zed in the interest of the c l ient ' s best socia l adaptation." 1 It is the intention of this analysis to examine whether caseworkers attempt to enhance the c l ient ' s social functioning, or whether changes and reorganization in the c l ient ' s personality structure is the main treatment objective. 1 Perlman, Helen H . , Social Casework. University of Chicago Press, Chicago, 1950. 12 The casework focus which is subscribed to in this study-entails treatment of the client and his dynamic inter-action with his problem situation. Psychiatric Contributions to Family Therapy: Dr. Ackerman suggests a framework for personality theory in which he has attempted to integrate intrapsychic and interpersonal processes: "Thus I regard the progressive stages of personality organization of the chi ld as advancing levels of biosocial inte-gration with, and differentiation from, the environment. The basic drives of the chi ld are to be evaluated within the frame of changing integrations of person-a l i t y and changing integrations of the individual into family relationships. At each stage of maturation, drive, defense, perception of se l f , perception of persons in the environment, conflict and anxiety are part ia l phases of integral units of adaptation. The urges for food, love, preservation of se l f , and sexual expression are structured by the contin-uous interplay of image of se l f and image of interpersonal experience with the s igni-ficant others in the family. Behaviour is goal-directed. The direction of s tr iv ing is determined by personal identity and value orientation. Pleasurable experience is sought, pain avoided. Pleasure may come with need satisfaction or new learning, the adventuresome exploration and expanding mastery of the outer world." 1 The balancing of inner needs with outer r ea l i t i e s , within and between family members, w i l l determine each 1 Ackerman, N.W., Psychodynamics of Family L i f e , p. 50. 13 individual 's adaptation to the group and to society. Inner needs and outer rea l i t ie s are, however, in a constant state of flux; the former change as maturation occurs, and as outer rea l i ty shif ts . To i l lu s t ra te , a traumatic experience to a ch i ld , such as the loss of a parent, may be offset by a parent surrogate and as his gr ief diminishes, by the chi ld ' s gradual acceptance of that loss. It becomes im-portant to look not only for pathology within an individual and his situation, but for areas of health as wel l , and i t is only recently that the concept of health is receiving some attention. Jackson and Sat ir , in reviewing psychiatric development in family diagnosis and treatment, state: "Gradually an awareness has been developing of the existence of health within the same framework in which pathology exists, which has led to a beginning re-evaluation of emotional i l lne s s . The concept of "adaptation" has helped focus on the "why" of the i l lness rather than on fixed psycho-pathological symptoms." 1 Dr. Ackerman suggests " . . . i t i s useful to think of the family as a kind of carrier of elements predisposing both to mental i l lness and mental health. Degrees of success or adaptation in the paired family roles of husband and wife, father and mother, parent and ch i ld , child and s ib l ing , bear 1 Jackson, D.D. , Sat i r , V. "A Review of Psychiatric Development in Family Diagnosis and Family Therapy", Exploring the Base for Family Therapy. F . S . A . A . , New York, 1961 14 direct ly on the question of staying well or getting i l l . What are the c l i n i c a l psychodynamics and social features which distinguish predomin-antly sick from relat ively healthy types of families?" 1 It i s not a simple task to distinguish health producing from pathology-producing family interrelationships for i t involves "the subtle and complex weave of relations of the individual to family group and accommodation of person-a l i t y to role requirements." Dr. Ackerman goes on to state the crucial question: "Is the integration of family re lat ion-ships preserved despite conf l ic t , or does conflict tend to destroy the family t i e , the l ink of the individual and family identity, and thus cause an intensif ication of individual pathology?" 3 These questions lead practitioners to search out the whys of family health and breakdown and, just as patterns of individual behaviour have been diagnosed and treatment geared to these diagnoses, may i t not be possible to identify patterns of family functioning as well? Social work has recently identif ied dist inct family types, based on economic, marital , and child-bearing patterns of functioning, which w i l l be described in detai l in Chapter 4« 1 Ackerman, Psychodynamics of Family L i f e , p. 104. 2 I b i d . . p. 112. 3 I b id . , p. 113. 15 Focus of Study This thesis w i l l attempt to assess whether the casework recording in a Child Guidance Cl in ic reflects a focus on the social functioning of a child and his family in ,the casework contribution to c l i n i c a l diagnosis and treatment of children's emotional disorders; or does the recording emphasize each family member's individual emotional problems? To paraphrase Dr. Sherman, does the psychosocial dichotomy exist in a Child Guidance C l i n i c , even though this setting has long recognized that the chi ld ' s behaviour is symptomatic of relationship d i f f i cu l t i e s between the parents and the child and, more recently, that his emotional problems are an expression of pathology within the whole family group? The diagnostic and treatment periods w i l l be separ-ated for the purposes of this study, although i t is recognized that they are complementary parts of the casework process in practice. Diagnosis is used here to designate that period of the family's contact with the C l in i c up to and including the diagnostic conference. This marks the termination of the team's formal study period and the formulation of treatment goals. Treatment designates the period immediately following the diagnostic conference to termination on the closed cases, and to the point of the latest entries in the active f i l e s . This study w i l l attempt to identify the information that is obtained from parents and other resources about their 16 disturbed chi ld , what the caseworker's evaluation of the problem i s , and what the treatment goals are. Particular emphasis w i l l be placed upon determining whether the case-recording reflects concentration on each individual member's emotional conf l icts , or upon the current socia l functioning of family l i f e which affects the chi ld ' s adaptation. Areas in the recording which are pertinent to this focus w i l l be identif ied, as well as relevant areas that are not recorded. Recommendations for a change in recording practices w i l l be made where indicated. Recording of the treatment period with the parents w i l l be studied, and such questions w i l l be asked as: why are family members assigned to one, or more than one worker; is there evidence of the caseworkers* awareness of current family relationships and how they affect the chi ld ' s emotional adjustment? A particularly significant question involves the caseworker's and family members* dis-cussion of treatment goals: how do parents perceive their roles in relation to the chi ld and to the caseworker in helping their younster? An attempt w i l l be made to determine i f there is a relationship between the outcome of treatment and the casework focus. While this study is mainly concerned with the identif icat ion of information and methods which contribute to family diagnosis and treatment, i t cannot be over-emphasized that the way in which the caseworker develops 17 and uses the treatment relationship is of the utmost import-ance in helping the cl ient achieve a more favourable adapt-ation to his family. I t is beyond the scope of this study to elaborate on this aspect of casework, but i t is recognized here as a basic element in the helping process. An analysis of the recording is not synonomous with an analysis of casework practice and s k i l l s . Many caseworkers give an excellent service without, however, recording the basis for their diagnosis and methods of treatment. Conversely, the recording of a l l facts that are pertinent to a psycho-log ica l diagnosis does not necessarily lead to s k i l l f u l practice. However, social workers are constantly seeking to understand which information should be obtained from the client in order to assess his participation in the problem he i s troubled with, and to work out with him, ways in which he can be helped to come to terms with his d i f f i cu l ty . The recording should reflect the caseworker's thinking in these areas. Such recording provides the caseworker with an opportunity to assess his own practice; i t i s also invaluable in supervisory discussions and in consultation with other disc ipl ines . Furthermore, well-kept records are essential for research purposes. More sc ient i f i c recording is only one of the avenues leading to improved casework services, but i t is a valuable tool which has not been adequately u t i l i zed by the profession 18 in i t s search to establish i t s own diagnostic and treat-ment methods. Concepts for Family Diagnosis: What concepts can be u t i l i zed in family diagnosis? Psychoanalytical theory provides a framework for depth understanding of the individual 's emotional l i f e . It permits caseworkers to estimate the c l ient ' s level of psychosexual development; to understand the defenses he ut i l i zes to handle his anxiety; to view the c l ient ' s be-haviour as purposeful i f the conscious and unconscious forces which underly his adaptation can be understood. It has taught caseworkers to look for cause and affect relationships between the c l ient ' s present behaviour and attitudes and his past history, particularly his experiences within his own family. Psychoanalytical theory has contr i -buted the concept of transference and counter-transference in the treatment relationship, that i s , that the caseworker and the c l ient may react to each other either positively or negatively as a result of past experiences in other important relationships;, Gordon Hamilton 1 outlines three major psycho-analytic contributions to casework: 1) The c l ient ' s account of his history and problem cannot be taken l i t e r a l l y . Be-1 Parad, H . J . , E d . , Ego Psychology and Dynamic Casework. F . S . A . A . , New York, I960, p. 18. ! 19 cause of his defensive structure, there is often distort ion. 2) The understanding of transference and counter-transference phenomena in the client-worker relationship. 3) Parents' complaints about their child are frequently a repetition of their own childhood experiences, and may have l i t t l e to do with the chi ld ' s actual problem. S imilar ly , the cl ient often displaces and projects his own unconscious wishes and fears onto other people in his environment. Psychoanalytic c oncepts contribute s ignif icantly to the diagnosis and treatment of an individual 's person-a l i t y problems which may be an important factor in the d i f f i cu l t i e s for which he is seeking help. Considerable l ight may be shed upon current inter-relationship d i f f i -culties within a family once the individual personalities of the participants are understood. A compulsive mother, for example, requests help for an exhibi t ionis t ic , acting-out ch i ld . His behaviour has made her very anxious, but she may be reacting towards the child in a way which pro-vokes further acting-out. Her anxiety over his behaviour may be a ref lect ion of her own unresolved conflicts in dealing with her aggressive and sexual impulses. The case-worker may have an excellent grasp of the mother's contri-butions to the child 's behaviour, and the reasons behind her conflicting expectations of him. How the worker uses this knowledge w i l l depend on her understanding of the 20 caseworker's function. There has been considerable dis-cussion on whether i t is a social work function to interpret underlying conflicts of which the client is not consciously aware. The view supported here is that interpretation of such material does not l i e within the province of casework, for i t s training does not equip i t s practitioners to under-take psychiatric responsibi l i t ies . The mother may, with sufficient support, make the connection herself, but even this insight w i l l be unfruitful i f i t does not result in improvement of her functioning as a mother. Psychoanalytic theory has contributed s ignif icantly to the part the individual 's emotional d i f f i cu l t i e s play in the problems for which he is seeking help. Treatment is f ac i l i t a ted by an understanding of transference and counter-transference phenomena. What these concepts cannot do, however, is provide a framework for evaluating other s igni-ficant factors in current family relationships and situations which are the external rea l i t i e s of the c l ient ' s problem. It remains for socia l work to adapt psychoanalytic knowledge to casework practice. The advent of ego psychology was one step in this direction. Howard Parad states: "Ego psychology provides us with a comprehensive approach to understanding how the human personality deals with the complicated network of forces 21 and counterforces from inst inct , conscience, and the larger  socio-cultural environment." 1 Annette Garrett states: "It is the sum tota l of the integrating efforts of the personality." The ego faces three ways, and receives stimuli from the i d , the superego, and external r ea l i ty . The impact of r ea l i ty on the individual is added to the Freudian concepts. The c l ient ' s ego strengths, that i s , his capacity to bear frustration for a purpose, i s given more recognition or, in other words, his current functioning and adaptability are assessed. Annette Garrett adds, "A f u l l appreciation of ego psychology reveals new meaning as we integrate the concept that the unconscious ego operations are manifested in a myriad of ordinary, day-by-day, characteristic ways of functioning." 3 In the pre-Freudian era, data on the c l ient ' s social functioning was routinely secured but i t s significance was not grasped. During the Freudian period, social workers lost sight of the value of knowing the facts of the c l ient ' s current l i f e s ituation, and how he expressed himself in the significant roles he was called upon to play. 1 Parad, H . J . , ed. , Ego Psychology and Dynamic Casework. F . S . A . A . , New lork , I960, p. 2. (underlining added}. 2 Garrett, A . , "Modern Casework: The Contributions of Ego Psychology", Ego Psychology and Dynamic Casework. Ed. by H.J . Parad, F . S . A . A . , New York, I960, p. 43. 3 I b id . , p. 46. 22 Since the facts of his social situation and adaptation were often not secured, i t was not possible to know how the client expressed himself in his daily behaviour, and valuable clues about his personality, his external rea l i ty , and his pa r t i c i -pation in his problem, were missed. Ego psychology recognizes the importance of del in-eating the c l i ent ' s personality as well as the nature of his s ituation. Florence Hol l i s states: "A thorough understanding of -the situation is necessary in part to determine whether changes can be brought about in the s i t -uation i t s e l f and, in part, to analyze speci f ica l ly what changes the cl ient him-se l f needs to make in order to relate him-se l f more constructively to his to ta l l i f e situation."* She adds: "I cannot overemphasize the importance of getting from the cl ient the concrete de-t a i l s of the daily and past events in his l i f e - of his actual functioning . . . We cannot rely solely on the c l ient ' s sub-jective reactions. It is only in this way that we can check for the internal consis-tency of his story, and estimate the adequacy of his reactions to his l i f e events and his interpretation of them...When i t comes to treatment i t s e l f , only specific material can be used in helping the c l i e n t . " 1 In Child Guidance practice, the chi ld ' s primary situation is his family mil ieu. His relationships with his parents and s ibl ings , and theirs with him, must be explored 1 Ho l l i s , F. "Personality Diagnosis in Casework", Ego  Psychology and Dynamic Casework. H.J . Parad, E d . , F . S . A . A . , New York, I 9 6 0 , p. 8 8 . 23 as fu l ly as possible, as well as any outside situations and persons which may have a bearing on the chi ld 's d i f f i c u l t i e s . Ego psychology has contributed to casework the importance of understanding the inter-action of the individual with his s i tuation. It represents a significant attempt in social casework to integrate the psychological and social factors which comprise the c l ient ' s problem. Role theory represents a further step in this direction, for i t provides a conceptual framework to delineate those areas in the c l ient ' s current functioning which are im-paired, and those in which his adaptation is favourable. Further, i t helps the caseworker identify the c l ient ' s major problem, and lesser, but related, d i f f i c u l t i e s . It cannot be overemphasized that role theory, without u t i l i z i n g psycho-logica l concepts, contributes l i t t l e to casework practice. It i s a sociological theory, and unless psychological under-standing is combined with i t , casework w i l l not develop, but could return to the sociological approach of the pre-Freudian era. It is worth reca l l ing that social work's excessive stress on the emotional adjustment of the individual was, in part, a reaction to discouragement over the minimal results that an environmental approach brought to families in distress. Role theory does not provide a method for simplified case-work practice; rather, i t adds a further dimension to the already complex body of knowledge. I f used in conjunction 24 with psychological concepts, i t holds the promise of pro-viding a method for family diagnosis. Sanford Sherman writes, " I f the socia l science concepts are viewed as a source of departure, and the psychological dimensions "bui l t i n " , there can be considerable reward in the new insights gained." ^ In a study enti t led "Role, Stress and Social Case-work Practice" 2 which drew its conceptual framework from 3 such sources as Werner W. Boehm's Curriculum Study, Jessie Bernard, ** and Dr. Ackerman, the author reached the con-clusion that social role theory would be a usable tool for family assessment. The significant features of social role theory in relation to family diagnosis w i l l be outlined below. This study concludes: 1 Sherman, Exploring the Base for Family Therapy, p. 17. 2 Hawley, G.M., Role. Stress and Social Casework Practice, Master of Social Work Thesis, U . B . C , 1961. 3 Boehm, Werner W., "Objectives for the Social Work Curriculum of the Future", Vol . 1, Social Work Curriculum  Study. Council on Social.Work Education, New York, 1959. 4 Bernard, Jessie, Social Problems at Midcentury, Dryden Press, N .Y . , 1957. 5 Ackerman, N.D. Psychodynamics of Family L i f e . 25 "The tremendous contribution of the social role theory is that i t leads from an understanding of individual dynamics to an understanding of family, group, and eventually community dynamics. While i t u t i l i zes psychoanalytic and ego psycho-logy theories, i t has integrated them with sociological theories, * or, in other words, has put out understanding of i n d i -vidual dynamics in a social context. Thus is provided a better balanced perspective of man in relation to society." 1 In addition, the author suggests that this theory provides a relevant base for involving the cl ient in the helping process. The caseworker c lar i f ie s her own role and the client learns what he can expect from the agency. There are three major concepts in social role , those of role , stress and problem. Social roles are viewed as units of socia l function-ing. The tasks described for specific roles are defined with some leeway by society. For example, under normal circumstances, parents are expected to provide for their children's physical and emotional needs, but how this w i l l be done, and to what extent, is not defined by society. Each individual functions in a variety of roles . An adult male may be a spouse, father, son, s ib l ing , employee, neighbour and so on; s imilar ly , a child may be a son, a s ib l ing , a grandchild, a pupil and a playmate. The way in 1 Hawley, Role. Stress and Social Casework Practice, p. 163. * The author questions whether this integration has actually been achieved, and believes further study is required" to accomplish this goal. 26 which he performs each function w i l l depend on his physical and inte l lectual endowments, on his emotional development and upon social factors. There are a number of components to the role concept. "Role perception" is the individual 's understanding of the requirements of h i s , and other people's, particular roles . "Reciprocity" refers to the relationships of the reciprocal roles, such as the marital or parent-child relationship. "Inter-relatedness of roles" refers to the effects of changes in performance of one role upon performance of other roles. Thus, i f a chi ld is experiencing d i f f i cu l t i e s in meeting the requirements of his school, his feelings of fear, inadequacy or resentment, may be expressed in other re lat ion-ships and tasks, particularly those which are connected with the school s ituation. In this way, impairment in one role can be related to dysfunctioning in another, and the connection made between the chi ld ' s school performance and his adaptation to other roles . Role network is a part icularly relevant concept for family diagnosis, for i t provides a view of the client as an inter-acting unit in a system of roles . It refers to the c l ient ' s major socia l relationships, to the functions he performs, as well as the reciprocal performance of those with whom he inter-acts. Since the chi ld ' s disturbance is con-27 sidered to be symptomatic of pathology within the family, an understanding of each member's role network may reveal the outstanding problem areas. Use of th i s concept would enable the caseworker to be more alert to the father-child relationship, as well as parent-sibling and chi ld-s ibl ing inter-action. Of particular significance i s the inclusion of the father in diagnosing and treating the chi ld 's dis-turbance. His relationship with the problem chi ld , as well as the resources he might contribute to his improvement, are too infrequently explored in Child Guidance C l in ic s . Simi-l a r l y , the position of siblings in the family, and their relationships with parents and the disturbed child are often overlooked. Without this knowledge, i t is impossible to formulate ideas as to the purpose the disturbed chi ld 's behaviour serves to the group, or to evaluate the stresses placed upon him, and the resources that are available to him in his own family. The role network concept does not provide an h i s tor ica l view of family relationships; i t describes their adaptation at one point in time. Obviously, a f u l l h i s tor ica l view of the family's network would be impossible to obtain. However, i f their present inter-action is understood, i t may be possible for the parents to r eca l l significant changes in their relationships with each other and with their 2$ children which would establish some hi s tor ica l perspective of the family as a unit , and which might shed more l ight upon the needs the chi ld 's disturbance is meeting. Through an understanding of the c l ient ' s role net-work, the caseworker can attempt to grasp the problematic inter-relationships amongst family members, and between the nuclear group and other significant persons and situations interacting with them. This knowledge is necessary to evaluate the possible sources of stress to which the family i s reacting, and which is finding expression in the emotional disturbance of one of i ts members. Stress is defined as a situation which involves threat to the performace of social ro les . The stress factor refers to the threats which arise within the individual (physical or psychological), or from his environment within his network of roles . The result ing role impairment w i l l be a secondary source of stress. Specific values w i l l be threatened, according to the individual 's emotional develop-ment and social s i tuation. An examination of the c l ient ' s values w i l l enable the caseworker to understand his sub-jective response in the context of his particular culture and class . To i l lu s t ra te , a chi ld who steals in a strata of society where delinquency is a definite pattern w i l l generally not create so much anxiety in the parents as the child from 29 a middle-class family whose parents are regarded as good ci t izens . Thus, the mores of the particular culture or strata of society to which the family belongs w i l l have a bearing on the way in which the parents react to irregular behaviour in one of i t s members. Their personal values w i l l also have a marked bearing on their reaction to stress. It may be extremely important to a mother, for a variety of reasons, to achieve success as a mother, and to raise physically and mentally healthy children. Only as the particular values which underly the mother's reaction to her chi ld are known can the caseworker empathize with her, and understand her reaction to the problem for which she is requesting help. The application of role theory helps to identify the major and related relationship problems which may be contributing to the chi ld 's disturbance. The carry-over of impairment from one role to another, and between one pair of relationships and another, can be recognized. This theory helps to identify the location of the greatest source of stress to the family, and to the ch i ld . It should be added that, through an assessment of the family members' role performance, areas of strength can be located. Casework attempts to build on the c l ient ' s resources, as well as helping individuals recognize and work 30 out their problems. It is therefore important to look for roles that are well and satisfyingly carried out, and tasks that are mastered. Multi-problem families experience role impairment in many, i f not a l l , areas of l i v i n g . The family's relationship with social institutions may be poor; adults are unable to carry spouse and parent roles; they may need to depend on others to provide for the family, and the children may be physically and emotionally neglected. Health prob-lems throughout the family are frequently an additional d i f f i cu l ty . With the average middle-class families who seek help at Child Guidance C l in i c s , their adjustment to society's customs and laws is usually good. Management of income may be a problem, but seldom are these families dependent upon outside resources for their sustenance. Housing f a c i l i t i e s are frequently adequate, sometimes luxurious. The fathers are usually steadily employed, and many of the mothers take pride in their home-making. Their children are well-cared^ for within the parents* means. Their role performance in major areas is usually adequate within society's standards. Problems arise, however, in the subtleties of role performance. The father may be an adequate provider but is dissat is f ied with his job status; the mother cares for her children, but may find her task more burdensome than rewarding; husband and wife may not contemplate separation or divorce, but find their marriage dissatisfying. Old conflicts are aroused by their relationship and they may unwittingly use their children 1 31 in their struggle with themselves and with each other. There are, therefore, many strengths to build on in a large percentage of families who seek help from a Child Guidance C l i n i c . A f a i r l y superficial examination of the role performance of each individual may reveal these assets. It is the more subtle elements of role performance, however, which require the application of psychological concepts to understand what is happening within a family that produces i l lness in one of i t s members. Once the individual family member's ego strengths have been assessed, and the main characteristics of their relationships with each other understood in relation to the disturbed chi ld ' s behaviour, the major problem(s) can be identi f ied. It is essential at this point to decide how the healthier family members can be mobilized to strengthen the ones who are under the greatest stress. To i l lu s t ra te , a distraught mother, overburdened with the care of an aiutistic chi ld , may need the security which a compulsive husband can provide. He may have personality problems of his own, but his very need to provide well for his family and to organize their l ives to some extent, may need to be supported, rather than questioned, and ways found in which his wife can share more fu l ly with him the chi ld ' s care. The mother, too, w i l l need the caseworker's support. She may need to share her anxiety and gu i l t , to express the 32 concern and resentment she feels towards the chi ld , but she also requires the s tab i l i z ing influence of her husband, which w i l l not be available to her i f he is deeply engaged in attempting to sort out his own confl icts . The goal of casework treatment with families i s to help them function more adequately as a group, and not to work out neurotic conflicts without reference to the main problem and the family balance. It is through a combination of role theory and ego psychology that casework diagnosis and treatment of the family can, to some extent, be achieved. Consideration is given not only to the individual 's emotional adjustment, but also to the relationship between his adaptation and the balance of health and pathology within the family. This is particularly significant in casework treatment with children. Because the chi ld ' s defenses are less fixed, his impulses are more easi ly expressed. I f he moves too quickly to express these impulses before his parents can tolerate i t , they may react by controlling him more severely, thus intensifying the conflict between them. Not only, then, does an ind i -vidual's ego strengths need careful assessment, but also the a b i l i t y of the family to withstand freer expression of the feelings which underly the chi ld ' s symptoms. The goal of improved functioning of parent and chi ld must be kept in steady focus by the caseworker. This may be achieved by helping a parent and child in their performance in related 33 roles, or in direct help with their attitudes which underly dysfunctioning in the parent-child relationship, or by a combination of both approaches. Role theory provides a dynamic picture of the individual client inter-acting with his family and with other people and situations outside the group. Ego psycho-logy contributes an understanding of each individual 's personality patterns. The caseworker must have this know-ledge to help parents improve their functioning. It should be noted, however, that helping the client understand him-sel f better w i l l not be any more beneficial than an edu-cational approach which does not take into account the c l ient ' s personality patterns, unless i t results in better role performance. This is the aim of casework and the test of the effectiveness of i t s service. Related Social Work Studies  The St. Paul Study : The St. Paul Study 1 i s a pioneer project in integration of services on two levels , the community and the family unit . Of particular relevance to this study is the Project's use of a soc ia l diagnosis and a "Prof i l e " for a tentative measurement of family functioning. This Profile brings together in an organized form a large amount of data 1 Geismer, L . L . and Ayres, B. Patterns of Change in Problem Families, Family Centred Project, Greater St. Paul Community Chest and Councils, Inc. , St. Paul, Minn., July, 1959. 34 about the family which explains how i t operates as a socia l unit . Nine areas of family functioning are outlined in order of the ir prevalence: Child care and tra ining ; individual be-haviour and adjustment; family relationships and unity; socia l a c t iv i t i e s ; relationship to family-centred worker; use of community resources; economic practices; health problems and practices; home and household practices. It was found that the problematic functioning in the less frequent areas was symptomatic of overall family disorganization. Conversely, dysfunctioning only in the more frequent areas does not presuppose family disorganization. Although a l l these classif ications are not relevant for application in a Child Guidance Cl in ic where the clientele f a l l generally within the middle class, i t would be enlightening to adapt a scaled pro-f i l e to establish a comparative level for middle-class family functioning. Such a profi le might lead to a c lass i f icat ion of interpersonal and social problems which these families experience. In addition to the Project's emphasis on diagnosis of the family's social functioning, two other aspects are relevant to this study. Concentrated services were given these families to help them improve their adaptation in the nine areas mentioned, and recording techniques were developed, so that research could be conducted on their use of case-work services. It became possible to compare their function-35 ing at the beginning of the project and upon completion of i t . Such research is essential i f a pi lot program is to have the support of i ts community. A similar analysis of casework services in agencies and c l in ic s is also necessary i f social work is to gain the community support i t needs. It follows that recording practices require con-siderable revision to enable the researcher to accomplish this goal. Current Theses on Casework Measurement  Varwig and McCallum Studies: These studies are more closely related to this thesis than the St. Paul project. The physically handi-capped chi ld , not the family, was the principal c l ient , and the family's social and emotional adaptation were studied in de ta i l . By employing a rating scale, i t was possible to compare the chi ld 's adaptation to his handicap to the social functioning of his family at the beginning of therapy and after a two-year treatment period. Both these studies showed a definite connection between the chi ld 's adaptability to his handicap and the s tab i l i ty of his family. Children of those families who suffered from social problems, such as economic hardships, were found,to have greater d i f f i -culties in adjusting to their handicaps than those children 1 Varwig, R. Family Contributions in Pre-School Treatment of the Hearing Handicapped Chi ld . M.S.W. Thesis, U.B.C. School of Social Work, I960. 2 McCallum, M . F . , Family Differentials in the Habilitation  of Children with Brain Injuries, M.S.W. Thesis, U.B.C. School of Social Work, 1961. 36 whose families did not encounter this problem. Where the major stress appeared to be inter-relationship d i f f i cu l t i e s , particularly in the marital relationship, threatening or causing the break-up of the home, the chi ld ' s inab i l i ty to make use of treatment was most pronounced. These theses established two things: 1} that casework service in c l in ics for physically disabled children f u l f i l s the important function of helping families with the problems which interfere with their child 's adaptability to his handicap; 2) improved recording methods to measure the chi ld 's and family's functioning between two points in time. Such a rating scale c lar i f ie s the casework service which is required, and can also be used to measure movement in the chi ld ' s and parents' socia l functioning as a result of pro-vision of these services. The focus of this study is different from the two projects mentioned, in that social work has long been recog-nized as an established part of Child Guidance operations. There is a need, however, to assess to what extent the chi ld ' s emotional disturbance is related to the family's current functioning Shd, more spec i f ica l ly , to identify those areas of dysfunctioning. I f the family's s t ab i l i ty can influence the child's adaptability to a physical handicap, then i t is l i k e l y to have an even greater effect on his a b i l i t y to over-come his emotional handicaps or problems. It is for this 37 reason that the child should be understood both as an individual with his own needs, drives, and confl icts , as well as a person interacting with other people, particu-l a r l y his family group, and in the relationship process, is influencing them and being influenced by them. The child is re la t ive ly helpless to change the conditions of his l i f e that are unsatisfactory to him, and must adapt in the best way he;.can to his primary group. The family milieu can therefore help him or handicap him. The Hawley Study: 1 This study on "Role, Stress and Casework Practice" attempted to apply role theory concepts to the casework re-cording of Child Guidance cases. The author concluded that some of the important roles performed by the cl ient and those in his role network were not recorded, with the result that diagnosis of the chi ld ' s and family's functioning was incom-plete. Some of the important areas which were omitted were the father-child relationship, s ib l ing relationships with the parents and the disturbed chi ld , and the family's inter-action with the community. The significance of the Hawley thesis for this study l i e s in the fact that the focus on the individual 's functioning and those in his role network can contribute to casework diagnosis of the family. The identif ication of 1 Hawley, C M . Role. Stress and Social Casework Practice. Master of Social Work Thesis, U.B.C. School of Social Work, 1961. 38 sources of stress to each family member, and their reaction to i t in terms of role impairment, c lar i f ie s the c l ient ' s interaction with his problem, as well as the impact of his reaction to stress on other family members. In Child Guid-ance C l i n i c s , the chi ld is the principal cl ient or patient. I f these aspects of his behaviour which appear to be a reaction to stress within the family can be identi f ied, the areas in which the family requires help in order to provide a more stable environment for him can be c l a r i f i ed . C l i n i c a l diagnosis w i l l reveal whether the c h i l d , as well as his parents, requires treatment. A second contribution this study makes i s in the area of standardizing recording which is valuable for re-search purposes. It has been mentioned that casework re-cording in most settings is not designed for research. Sc ient i f ic analysis of the problems which are brought to social workers, and of the service given, is therefore extremely d i f f i c u l t to undertake. The Hawley study suggests a method for standardizing the recording. Material for comparing the individual 's social functioning, and the family's adaptation, between two or more points in time, would be readi ly available. The Hawley study was concerned primarily with the application of role theory to casework practice. Psychological 39 concepts were mentioned, but were not emphasized. Role theory can identify the problems within a family and the child's reaction to them in terms of his social functioning. This present study emphasizes the necessity of using psycho-logical concepts as wel l , in order to understand what l ies behind the outward behaviour of family members. Selection of Sample Cases: Cases of children between five and ten years of age, l i v i n g in their own families, and who received treat-ment in 1961, were selected. The recent year of act iv i ty was chosen so that an assessment could be made of current recording practices. Age selection is based on the operation of the two main treatment teams in this particular c l i n i c . One team is concerned with children up to eight years of age; the other accepts children over eight and under eighteen years. It was considered that this selection would give the best cross-sectional picture of casework recording. The choice of children l i v i n g in their own homes with both parents is self-evident for this family-focused study. Cases were omitted where severe physical handicaps on the part of the child complicated family problems, as were those cases where the chi ld was considered too i l l emotionally to attend public school. A further consideration was the achievement of the diagnostic study and, preferably, at least s ix months of treatment following assessment. Approximately th ir ty 39 cases met these requirements. Of this number, twenty were selected because of time limitations and the ava i l ab i l i ty of the f i l e s at the time they were required for this study. Some of the writer's own cases are included, and attempts have been made to assess these as objectively as the other cases. Setting of Study The setting of this enquiry is the Children's C l i n i c , Mental Health Centre, formerly known as the Child Guidance C l i n i c . Although the Cl in ic has other functions in addition to helping emotionally disturbed children, these w i l l not be enumerated since they are irrelevant to the scope of this study. Staff ratios are approximately four social workers to one psychiatrist , and two social workers to one psychologist. This means that social workers carry the largest number of treatment cases. The Cl inic is a Provincial Government service and is available to families residing in the province, although for practical purposes, treatment services are confined to adjacent municipalities. Intake is controlled to ensure quality of service, and parents are encouraged to seek help elsewhere when overloading may threaten this objective. This C l i n i c , in company with most Child Guidance settings where the demand for service exceeds the supply, has suffered 40 intermittently from waiting l i s t s and a highly selective intake. For this reason, i t would seem timely to study the current recording to determine whether new concepts in family diagnosis and treatment are being u t i l i z e d . The writer recognizes that new concepts cannot be accepted and ut i l i zed without study, testing and evaluation, but offers this piece of research as a contribution to this process. Methodology Methodology for this study has been adapted from two sources, the Varwig ^ and McCallum 2 theses on physically handicapped children and their families. The Varwig and McCallum studies employed two formulated schedules to rate the physical, soc ia l , intel lectual and emotional adaptation of the chi ld and the soc ia l functioning of his parents at two points in time. A rating scale was developed which measured movement in the chi ld ' s adaptation to his physical handicap, and in the parents* functioning. Comparisons were then made between a chi ld ' s progress in treatment and the s tab i l i ty of his family. It was the original intention of this study to devise a similar rating scale. However, there was not sufficient material in the casework recording during the 1 Varwig, Family Contributions in Pre-School Treatment of  the Hearing Handicapped Chi ld . 2 McCallum, Family Differentials in the Habil itation of  Children with Brain Injuries. 3 The schedules adapted from these for the present study are reproduced i n appendices A, B. 41 treatment period to measure movement of the chi ld ' s adap-tation to his emotional problems and the parents' social functioning. Furthermore, the Varwig and McCallum studies had at their disposal periodic medical assessments regarding the extent of the child 's physical impairment. Such material can be equated to the psychological and psychiatric assess-ments of the chi ld 's emotional adjustment in the Children's C l i n i c . However, diagnosis of the chi ld 's adaptation is recorded only during the study period, so that there are no standardized devices to measure movement in the chi ld ' s emotional development. Psychological assessment of the chi ld when treatment terminates would be extremely useful for research purposes. The two schedules can be applied only to the diag-nostic stage of each family's contact with the C l i n i c . Attempts w i l l be made to compare the extent of the chi ld ' s disturbance with parental attitudes and relationships, with areas of dysfunctioning within the family, and with s igni-ficant relationships and situations outside the group. These comparisons w i l l not be tabulated s t a t i s t i ca l ly be-cause of the lack of specific information in the recording. Only general trends w i l l , therefore, be described. One of the procedures which w i l l be given particular attention is the socia l history outline. 42 Regarding assessment of the family's function-ing during the treatment period, there are s u f f i c i e n t case-work evaluations i n some records on at lea s t one family member to describe whether the parent's r e l a t i o n s h i p to his c h i l d , and in some instances, to his spouse and other im-portant people in his environment, have improved. In no cases, however, were assessments recorded on a l l family members involved i n treatment. In those records which did evaluate one c l i e n t ' s functioning, s u f f i c i e n t material was available to describe, generally, whether or not movement had occurred. An attempt w i l l be made to r e l a t e improvement in family member's functioning to the casework focus. I t should be possible to hypothesize whether one fac t o r i n the c l i e n t ' s movement i s due to a casework emphasis on his emotional c o n f l i c t s , r elated to his own early experiences, or whether the focus on the c l i e n t ' s current i n t e r a c t i o n with his role network might have contributed to his improved adaptation. Schedule "A" (see Appendix 1) w i l l be used to evaluate the child's functioning. I t comprises the follow-ing components: the c h i l d ' s evaluation of himself; his view of his relationships with father, mother, s i b l i n g s and peers and his place i n the family group. These factors are e s s e n t i a l l y subjective i n nature. A second major area 43 comprises objective components, such as the psychologist's evaluation of the chi ld ' s emotional maturity and function-ing, based on observation and the tabulated results of standardized psychological tests. An objective view of the chi ld ' s functioning is also obtained by school adjustment, the " a b i l i t y to relate" and "evaluation of emotional dis-turbance" categories. It is implied in the "Symptoms of Disturbance" class i f icat ion insofar as neurotic children are thought to be somewhat higher on the ego spectrum than children with predominantly behavioural symptoms of distur-bance. Most of the material for Schedule A was readily available from psychological reports, while "physical devel-opment", school adjustment and symptomotology were taken from the soc ia l histories . Schedule "B" attempts to evaluate parental attitudes towards the c h i l d , family inter-relationships, the sol idar i ty of the group, socio-economic conditions, and the family's interaction with their community of residence. This schedule does not lend i t s e l f to an objective and subjective c lass i-f ication of parental and family functioning, for this infor-mation is collected by the caseworker in a series of re la t ive ly unstructured interviews, and evaluations are not so precisely articulated as in the psychological reports. Parents are understandably guarded in expressing some of their real attitudes towards spouse, parents and children, and i t i s 44 frequently not u n t i l later interviews that the f u l l range of their attitudes, and how these affect their role performance, are understood by the caseworker. In some cases, tentative evaluations of marital and parent-child relationships were made by the caseworker, while in other records, i t was necessary to draw arbitrary conclusions from inferences in the f i l e s , part icularly in the area of marital and father- . child relationships. The two schedules, taken together, establish to a limited extent, role reciprocity . The application of these schedules to the sample cases w i l l point up areas of information that are recorded, and those that are not. It w i l l be possible to assess whether casework is concerned mainly with emotional factors in each family member's adjustment, or whether their adapt-ation to each other and to the social conditions of their l ives contribute to the psychosocial diagnosis. Schedule "B" w i l l explore to what extent assessments are made of family relationships, and whether, in fact, the chi ld ' s symptoms are judged to be an expression of pathology in the whole family's adaptation. Since the most common-problem-to-be-worked in a Child Guidance Cl in ic is the parent-child relationship, Schedule n B " w i l l i l lus tra te whether caseworkers explore the inner and outer strengths and stresses that impinge on that relationship. 45 Tthis study must be regarded as exploratory, because of the limited number of cases. Nevertheless, an analysis of c r i t i c a l points relat ing to family casework w i l l be attempted. Chapter .72. CLIENT AND FAMILY ASSESSMENT IN DIAGNOSIS Symptoms o f Emotional D i s t u r b a n c e i n C h i l d r e n : What are some o f the symptoms o f di s t u r b a n c e t h a t b r i n g parents t o c o n s u l t a C h i l d Guidance C l i n i c ? Stone and Church, from e x t e n s i v e c l i n i c a l experience r e c o r d e d i n t h e i r book, Childhood and Adolescence suggest t h a t emotional d i s t u r b a n c e s i n the t o d d l e r and p r e - s c h o o l years are manifested i n such symptoms as s k i n i r r i t a t i o n s or e r u p t i o n s , j e r k y or f l a c c i d body movements, s l e e p d i s -turbances such as nightmares and bedtime f e a r s , v o m i t i n g , e x c e s s i v e h a n d l i n g o f the g e n i t a l s and en e u r i s e s and s o i l i n g past the age of f o u r . The authors s t a t e "Emotional upset at t h i s age i s t i e d t o body f u n c t i o n i n g , whether v e g e t a t i v e or motor, and may foreshadow h y s t e r i c a l and psychosomatic 2 m a n i f e s t a t i o n s o f l a t e r y e a r s . " They suggest the most prominent d i f f i c u l t i e s o f t h e middle y e a r s , i . e . s i x t o twelve y e a r s , r e v o l v e around s c h o o l i n g and the c h i l d ' s a b i l i t y t o l e a r n . In a d d i t i o n , p e r s i s t e n c e o f behaviour which was qu i t e normal a t an e a r l i e r s tage, such as speech d i f f i c u l t i e s , tantrums, thumb s u c k i n g and e n e u r i s e s are co n s i d e r e d t o be symptoms o f d i s t u r b a n c e i n t h i s age group. 1 Stone, J.L. and Church, J . Childhood and Adolescence. London House, New York, 1957* 2 I b i d . , p. 355. 47 The c h i l d may be m a n i f e s t i n g a b n o r m a l s o c i a l b e h a v i o u r > r a n g i n g f r o m w i t h d r a w a l , f r o m s o c i a l p a r t i c i p a t i o n o r o v e r c o n f o r m i t y , t o d e l i n q u e n c y , a l t h o u g h t h e l a t t e r symptom i s u s u a l l y a s s o c i a t e d w i t h t h e a d o l e s c e n t p e r i o d . N e v e r t h e l e s s c e r t a i n d e l i n q u e n t t r a i t s may a p p e a r i n t h e c h i l d o f t h i s age, s u c h as s t e a l i n g , v a n d a l i s m and p h y s i c a l a g g r e s s i o n . The a u t h o r s draw a d i s t i n c t i o n b etween v a r i o u s t y p e s o f d e l i n q u e n c y r a n g i n g f r o m (a) n o r m a l o r c a s u a l de-l i n q u e n t b e h a v i o u r i n s i x a n d s e v e n y e a r o l d s , s u c h a s a l i m i t e d amount o f e x p e r i m e n t a l s t e a l i n g f r o m p a r e n t s , t o (b) p s y c h o p a t h i c d e l i n q u e n c y , i n w h i c h t h e c h i l d h a b i t u a l l y e n gages i n d e l i n q u e n t a c t s w i t h no a p p a r e n t i n n e r c o n f l i c t as he i s v i r t u a l l y l a c k i n g i n c o n s c i e n c e . Somewhere between t h e s e e x t r e m e s o f n o r m a l t o a b n o r m a l d e l i n q u e n c y l i e s t h e c a t e g o r y o f " n e u r o t i c d e l i n q u e n c y " , i n w h i c h t h e c h i l d who f e e l s i s o l a t e d , s t e a l s f r o m p a r e n t s t o e x p r e s s h i s n e e d f o r l o v e as w e l l as h i s a n g e r a t them f o r d e p r i v i n g him o f l o v e . M a r g a r e t W. G e r a r d 1 d i s c u s s e s p s y c h o l o g i c a l d i s -t u r b a n c e s i n c h i l d r e n w i t h i n t h e framework o f F r e u d i a n t h e o r y . She d e s c r i b e s p r o b l e m s i n t h e o r a l , a n a l , o e d i p a l , l a t e n c y , and a d o l e s c e n t s t a g e s o f d e v e l o p m e n t . She s t a t e s : "When we speak o f p s y c h i c d i s o r d e r s i n c h i l d h o o d , be t h e y c l a s s i f i e d as b e h a v i o u r p r o b l e m s , n e u r o s e s , o r 1 G e r a r d , M.W., " E m o t i o n a l D i s o r d e r s o f C h i l d h o o d " , Dynamic P s y c h i a t r y , E d . b y A l e x a n d e r a n d R o s s , U n i v . o f C h i c a g o P r e s s , C h i c a g o , 111., 1957. us autonomic symptoms, we are concerned in general with the disorders in adap-tation to the environment in which the child finds himself. For this reason, some behaviour may be considered ab-normal in one environment and not in another Similar differences occur within a culture from one socia l group to another and are superf ic ia l ly ev i-dent in differences in manners, sexual behaviour and so forth. In even greater degree, differences occur from one age to another. What may be a serious symptom in an adult may represent normal behaviour for a two-year-old and only questionable behaviour in a five-year-old, as, for example, nocturnal bed wetting, temper tantrums, fantastic ly ing , genital ex-posure. It is obvious that consideration of a disorder must always be undertaken in view of the expected or "normal" be-haviour of a chi ld at the age of occurr-ence and with recognition that environ-mental demands and expectations change with the age of any c h i l d . " I What constitutes emotional disturbances in children then, varies according to the age of the child and the cultural and social norms of his environment. In addition, certain modes of behaviour which may be considered symptomatic of disturbance at one period of time in society may be viewed as normal at another period, as for example thumb sucking past infancy and "eneurises" and " so i l ing" past the age of two. However, within the context of society's expectations of children at given ages, Dr. Gerard describes emotional disorders at the various stages of development. The present 1 Gerard, Dynamic Psychiatry, pp. 167-168 49 study is concerned only with the oedipal and latency periods, although Dr. Gerard states, and Stone and Church confirm, that symptoms which develop in any age past infancy may be a carryover of unresolved problems from a former stage or stages. Dr. Gerard describes the symptoms of the oedipal or sexual period (beginning around three and last ing approxi^ mately unt i l six years of age) as excessive masturbation, feelings of in fer ior i ty , and fear of injury which, when i n -tensif ied, may lead to 'peeping", exhibiting of genitals, "tomboy" behaviour in g i r l s or "sissy" behaviour in boys, and r iva l ry complicated by exaggerated rage, stubborness, dependent longing and greed. Anxiety symptoms may become excessive with repetitious nightmares and fear of the dark, of new situations and strange persons. Phobias may arise to displace the more generalized anxiety. Pathological motor ac t iv i t i e s , such as stammering and t i c s , may begin, as well as asthma, enuresis, constipation, co l i t i s and feeding di f f i -cult ies . She concludes: "Indications of some unacceptable behaviour symptoms are often found at this time, such as sadistic cruelty and masochistic submission, uncontrollable stealing and ly ing , insatiable demanding with concomitent selfishness." 1 1 Gerard, Dynamic Psychiatry, p. 171• 50 The latency period delineates those years between the sexual period of the oedipal phase and the sexual matur-ation of adolescence, and extends from approximately six to twelve years. Because this is the period in which the chi ld is developing standards of behaviour, he undertakes many experiments so that symptoms may occur transiently and then give place to more adequate behaviour. Psychopathology in childhood is suspected only when a symptom remains fixed in spite of i t s adaptive inadequacy. I f transient symptoms are replaced by other symptoms, however, i t i s l i k e l y the child is emotionally disturbed. Dr. Gerard classif ies the psychic disturbances of this period into the following categories: 1) Infantile phenomena or marked developmental immaturity; 2) motor disorders; 3) conduct problems; 4) common neuroses; 5) vegetative disorders, and 6) psychosis. Infantile phenomena include various infanti le ac t iv i t ie s such as thumb-sucking, incontinence, or excessive masturbation; motor disorders occur as excessive purposeless ac t iv i ty , inhibit ion of movements, awkwardness, t ics and stammering; conduct problems cover a variety of symptoms from withdrawn behaviour to aggressive conduct disorders ranging from mild disobedience and stubbornness to serious de l in-quencies. Under common neurosis are included the various neurotic constellations such as phobias, compulsions, 51 hysterical phenomena, learning inhibit ions; vegetative  disorders comprise a l lergic disorders and other organic diseases which are thought to be psychogenic in origin such as duodenal ulcer and ulcerative c o l i t i s . The psychoses comprise those cases which disclose severe , pathological ego defects, disorientation to rea l i ty , and delusional l i f e . What causes these psychic disturbances in chi ld-hood? The development of the child occurs as a result of the "interaction between the maturational processes and environmental influences." According to the Freudian frame of reference, conflicts for the child arise between " inst inctual drives and environmental demands, between instinctual drives and superego standards and between opposing ins t inct s . " ^ A healthy adjustment follows when these various demands are satisf ied in a balanced way, but symptoms of the kind enumerated above appear when methods of solving these intra-psychic and inter-personal conflicts are unsatisfactory. While constitutional factors such as inte l lectual capacity and physical endowment, may play an important part in the chi ld ' s development, his family plays 1 Gerard, Dynamic Psychiatry, p. 168. 2 Loc. c i t . 52 the exceedingly prominent role of interpreting to the child the rules which society expects him to obey, and by example and expl ic i t instruction show him the ways in which he can direct his energy to conform and s t i l l gain satis-factions for his needs. The personalities of the chi ld ' s mother, father, siblings and other people in his environ-ment w i l l strongly influence the chi ld ' s choice of modes of impulse and relationship satisfactions. Since the young child is so close to, and dependent on his parents, part i-cularly the mother, he tends to react to both her conscious and unconscious wishes, and later , his father's , in ways which he perceives w i l l please his parents i f his feelings towards them are predominantly posit ive. Conversely, he tends to frustrate his parents' expectations i f his relat ion-ship with them is predominantly negative. Celia Mitchel l suggests that one chi ld in a family may be selected by one parent to "represent the unacceptable part of the parent's personality - the aggressive, the greedy, or the unsuccessful element - while another child has always been the lovable one." 1 Vogel and Bell^ hypothesize that the disturbed family group, led by the parents, selects one child to act out unresolved conflicts which would otherwise threaten the survival of the family. It is frequently when the child moves beyond the 1 Mitche l l , Cel ia , "A Casework Approach to Disturbed Families", Exploring the Base for Family Therapy, F . S . A . A . , N . I . , 1961, p. 80. 2 B e l l , N . W . , Vogel, E .F . A Modern Introduction to the Family, Free Press, Glencoe, 111., I960. 53 primary group i n t o the community and h i s symptoms cause neighbours, t e a c h e r s and doctors concern, t h a t the parents become s u f f i c i e n t l y m o b i l i z e d to seek h e l p f o r the c h i l d . T h i s may serve to e x p l a i n i n p a r t the reason f o r p a r e n t s ' concern i n t h e i r c h i l d r e n ' s adjustment to elementary s c h o o l . Symptoms of emotional d i s t u r b a n c e i n c h i l d r e n are considered, then, to be the outward m a n i f e s t a t i o n o f i n t r a -p s y c h i c c o n f l i c t s and unhealthy r e l a t i o n s h i p s w i t h one or both parents or w i t h the e n t i r e f a m i l y group. I t should be c l e a r t h a t a thorough understanding o f the i n n e r c o n f l i c t s a c h i l d s t r u g g l e s w i t h d u r i n g the f i v e main stages of h i s development i s e s s e n t i a l f o r s o c i a l work p r a c t i c e i n a c h i l d guidance c l i n i c . However, i t would a l s o seem to be very r e l e v a n t f o r d i a g n o s i s and treatment o f c h i l d r e n ' s emotional d i s o r d e r s t o have an accurate knowledge o f f a m i l y members' repeated responses t o the c h i l d and the purpose h i s behaviour f u l f i l s f o r the f a m i l y . C e l i a M i t c h e l l supports t h i s view when she says, "Only i f the e n t i r e f a m i l y group i s seen i n the process of i n t e r a c t i n g can the worker see the a c t u a l , r a t h e r than the p r o j e c t e d , p i c t u r e . As a r e s u l t , the worker's e n t i r e c o n c e p t u a l i z a t i o n and management of the problem are a l t e r e d . " I 1 M i t c h e l l , G e l i a , E x p l o r i n g the Base f o r Family Therapy, 1961, p. 81. 54 Symptoms o f Disturbance i n the Sample Group Many o f the symptoms d e s c r i b e d above appear i n the sample group. In none of the twenty cases s t u d i e d d i d parents complain of o n l y one symptom,- r a t h e r , each case shows a c o n s t e l l a t i o n of t h r e e or more symptoms, some o f them e a s i l y r e c o g n i z e d by the parents as i n d i c a t i o n s of maladjustment, while others are viewed as evidence o f the c h i l d ' s w i l l f u l n e s s , "bad*1 nature or poor p h y s i c a l h e a l t h . Frank emotional d i s t u r b a n c e s , e x e m p l i f i e d by a c h i l d ' s obvious l a c k o f c o n f i d e n c e , s l e e p l e s s n e s s , e x c e s s i v e c r y i n g , t i c s and f e a r s and phobias were found i n h a l f o f the sample. These may be thought of as "neurotic* 1 d i s t u r b a n c e s s i n c e these c h i l d r e n seemed to be c o n t a i n i n g t h e i r c o n f l i c t s w i t h -i n themselves, compared to those c h i l d r e n who were a c t i v e l y and a g g r e s s i v e l y behaving i n a h o s t i l e and more a n t i - s o c i a l f a s h i o n , and were p r e s e n t i n g d i s c i p l i n a r y problems t o t h e i r p a r e n t s . The problems of these c h i l d r e n a r e symptomatic of behaviour d i s o r d e r s . S p e c i f i c a l l y , these symptoms c o n s i s t e d o f stubbornness, r e s i s t a n c e t o p a r e n t s ' d i s c i p l i n e , d e s t r u c -t i v e behaviour and p e t t y p i l f e r i n g . There were n i n e cases i n which parents complained about such symptoms i n t h e i r c h i l d r e n . One case o n l y was found t o f a l l i n both c a t e g o r i e s , but f u r t h e r i n v e s t i g a t i o n r e v e a l e d t h a t t h i s p a r t i c u l a r c h i l d responded t o d i s c i p l i n e by r e i t e r a t i n g t h a t no one l o v e d him, thus making i t d i f f i c u l t f o r the mother t o c a r r y through on her requirements o f t h e c h i l d , r a t h e r than the youngster 55 engaging in destructive and defiant behaviour. Stealing was reported as occurring in only two cases; actively de-structive behaviour occurred in three instances. School problems in terms of the child's ina b i l i t y to cope with academic requirements occurred in ten of the cases; ages of these children ranged from six to ten years. Of these children five suffered from neurotic symptoms while five were described as discipline problems in their homes; in this sample, therefore, there is no correlation between school failure and the type of symptoms the parents describe in their children. This cannot be considered absolute, how-ever, since there are li k e l y many variations according to each parent's perception of what constitutes a disciplinary problem or a manifestation of a neurotic conflict. Two children were reported as having mild speech defects while three children were eneuritic or soiling. Eight children had d i f f i c u l t i e s in peer relationships, three because they were too "bossy" and stubborn with peers, and five because they were too shy and reticent to involve themselves very much with playmates; the former three children f a l l into the disciplinary problem category while the latter five a l l belong to the neurotic classification. Only two children were showing obviously psychosomatic symptoms, such as asthma, but this is to be expected since the case selection omitted children suffering from serious and handicapping 56 physical i l l n e s s e s . I t i s i n t e r e s t i n g to note, however, that, even though these children are considered to be in good health, s i x t y percent had suffered one very serious i l l n e s s in the past or were unusually susceptible to minor inf e c t i o n s , while one c h i l d or f i v e percent had had frequent serious i l l n e s s e s . Thus, judging from the symptoms described by the parents, the sample divides almost evenly into two categories: (a) those children who are obviously unhappy and tend towards self-punishment; and (b) those who are a c t i v e l y engaged i n c o n f l i c t s with t h e i r parents and punish others. The f i r s t group may be thought of as more frankly neurotic than the second, but the behaviour disorders i n the second group appear t o be mild and do not, except i n one case, constitute a problem outside the family except i n the area of learning d i f f i c u l t i e s , a problem shared almost evenly by the two groups. These two main categories t o t a l eighteen cases; of the two remaining cases, one c h i l d was considered to be r e l a t i v e l y healthy following c l i n i c a l i n v estigation, while the second c h i l d was moderately disturbed but parents' concern about h i s poor school progress caused them to concentrate i n i t i a l l y on t h i s symptom, and i t was not u n t i l l a t e r that they described other problems. Formal learning i s the one a c t i v i t y that takes place outside the families about which 57 parents expressed concern. Half the cases presented the child's learning d i f f i c u l t y as a major problem, despite the fact that a l l the children with the exception of one, tested within the average to superior range of intelligence* This is particularly significant in view of the fact that, at the time of parents" application, six children of the sample group were five years of age, five were six years old, two were seven, two eight, three were nine and two ten years of age. Some children, then, were not attending school although of these non-attenders at least one had experienced d i f f i c u l t y in kindergarten, and another child had been evaluated as unready for school on the basis of psychological tests. Since only one child was lacking in native intelligence, i t may be postulated that unfavourable attitudes towards learning were interfering with their response to formal education, and that these attitudes were l i k e l y developed in the interaction between mother-father-child. > From the point of view of obvious relationship d i f f i c u l t i e s within families, these cases constitute excel-lent material for the purpose of this study, which is to evaluate whether social workers diagnose and treat family relationships in a particular child guidance c l i n i c . In addition, these children and most of their parents have favourable physical and intellectual constitutional endowments. 58 C l i n i c a l evaluation revealed that slow emotional develop-ment was the main problem area of most of these children; one child was considered "normal" in emotional development. The information on his interviews was meager, but from available recording he indicated independence and self-assurance appropriate to his age. Ten children were con-sidered to be somewhat immature in terms of requiring more frequent assurance and support than "normal" children in their age groups, while nine children were described as being markedly underdeveloped emotionally. Their behaviour was characterized by excessive dependency on the parents or by denial of normal dependency needs. Socio-Economic Factors in the Sample Cases A s imilar homogeneity is found regarding socio-economic factors in the sample group. Most of the families can be placed in the middle-class strata of society ji-ged by occupation, income and l i v i n g standards, although i t is impossible to be very accurate in this area because of the incompleteness of some of the recording for the particular requirements of this study. Since the Cl in ic is a free service, there is no need to obtain exact information as to a family's income and expenditures; most of the interviews take place within the C l i n i c , so that income and l i v i n g standards, unless they constitute a definite problem for the parents, are not l ike ly to be discussed. Much of the 59 material for this section was taken from inferences in the recording rather than from exp l i c i t information. Seven of the fathers had good work records with permanent employment; seven were employed but their positions were tenuous because of economic conditions, relationship d i f f i cu l t ie s with the employer, or other dissatisfactions with their jobs. There was insufficient recording in five cases to classify these families" economic conditions. In thirteen cases, the fathers appeared to have been adequately educated and trained to maintain their current positions. Three fathers had obtained part ia l t ra ining, with the possi-b i l i t y of completing i t ; two had no specific training and two cases were not recorded. None of the mothers held positions outside the home, although two of them supplemented the family income by part-time jobs in the home. Generally speaking, economic problems are not prevalent amongst families attending the C l i n i c . This may be explained by the kinds of d i f f i cu l t i e s a family is struggling with. I f there are severe economic crises, the parents' energies are taken up with providing shelter, food and clothing for their family. However, i f parents can anticipate a regular income, they become more aware of unmet emotional needs. There is limited discussion, therefore, between the parents and caseworker regarding the family's 60 economic conditions. More exploration of certain aspects of t h e i r f i n a n c i a l s i t u a t i o n would, however, throw some l i g h t on family functioning. In some cases, i t might be of value t o explore both the f a t h e r T s and mother's attitudes towards his employment, how the father functions i n his pos i t i o n , and whether any p a r t i c u l a r stresses in t h i s area impair parents' relationships with each other. A r e l a t e d area that requires more c l a r i f i c a t i o n i n cases where parents complain of i n s u f f i c i e n t funds or tenuous employment, i s f i n a n c i a l management. Who handles the money and how, would highlight dominant and submissive c h a r a c t e r i s t i c s i n the parents, and would give some in d i c a t i o n of how they relate to each other. None of the cases studied recorded any aspect of f i n a n c i a l management, although t h i s was a problem i n at least four instances. Most of the families have been residents of B r i t i s h Columbia for some years although few are native to the province. One family had immigrated to Canada from the B r i t i s h I s l e s three years ago, and two families had recently moved from other parts of Canada. These circumstances constituted s p e c i a l problems of adjustment for a l l three, i n terms of loss of close relationships and a temporary lowering of l i v i n g standards. One family i s of the Jewish f a i t h , the rest are C h r i s t i a n . In only three cases, however, was there much a f f i l i a t i o n with a r e l i g i o u s i n s t i t u t i o n . 61 The Family's Relationship with the Community Only two families indicated positive, close relationships with neighbors and active participation in community affairs; seven families appeared to have minimal contact with people in their immediate vi c i n i t y while two families were openly hostile towards the people and i n s t i -tutions in their d i s t r i c t . Of these two latter families, one child was considered to be a severe disciplinary problem and the other child was nervous. Eight cases did not describe the families" interaction with their community of residence. Some exploration of families' relationships with their commun-ity might point up family patterns of relating which could have an important bearing on diagnosis and treatment-; for example, the child who is experiencing d i f f i c u l t i e s with playmates may be reflecting the parents' withdrawn or aggres-sive patterns in relationships, and the whole family may require help to involve themselves in a more satisfying way with the people with whom they could have almost daily contact. Furthermore, valuable resources which could strengthen the family might be discovered. Some mental health workers be-lieve that emotionally i l l people who appear to make spontan-eous recoveries have the a b i l i t y to seek out healthy people in their environment which fa c i l i t a t e s their recovery. Per-haps one way of helping the family with the problem child l i e s in strengthening their ties with their community of residence, or at any rate to ascertain whether there are potential sources of strength or of stress in this area during the fact finding period. 62 I n t e r - r e l a t i o n s h i p s w i t h i n the Sample F a m i l i e s Information on i n t e r - r e l a t i o n s h i p s w i t h i n the f a m i l i e s was taken from two main sources: the parents' view, excerpted from the s o c i a l h i s t o r i e s and in t a k e notes; and t h e c h i l d ' s view, taken from psychology r e p o r t s and p s y c h i a t r i s t ' s n o t e s . I t was i n t e r e s t i n g t o compare the pa r e n t s ' concepts o f t h e i r r e l a t i o n s h i p w i t h the c h i l d w i t h h i s a t t i t u d e towards them. More w i l l be s a i d about t h i s below.. In some cases i t was d i f f i c u l t t o e v a l u a t e e x a c t l y how t h e parents d i d f e e l about the c h i l d f o r whom they sought treatment. T h i s i s p a r t l y due t o the f a c t t h a t parents a r e o f t e n too f e a r f u l t o r e v e a l n e g a t i v e a t t i t u d e s about t h e i r c h i l d i n the e a r l y stages of c o n t a c t . Often they f e e l h i g h l y ambivalent because the c h i l d has become a source o f embarrassment and co n f u s i o n t o them, and whatever d i s t o r t e d the r e l a t i o n s h i p i n i t i a l l y has become complicated by the c h i l d ' s response to p a r e n t a l a t t i t u d e s . Parents a r e f r e q u e n t l y f e a r f u l o f c r i t i c i s m from the " e x p e r t s " , whom they know advocate g i v i n g as much l o v e and understanding to youngsters as p o s s i b l e , and they may f e e l g u i l t y t h a t they have been unable t o meet what they c o n s i d e r the expected standards t o be. In a d d i t i o n , the d i s t u r b e d c h i l d may be an important f a c t o r i n the d e l i c a t e balance o f n e u r o t i c f a m i l y r e l a t i o n s h i p s , which parents may u n c o n s c i o u s l y f e a r 63 to disturb. I t i s no wonder, then, with parents" conscious and unconscious hopes, fears and defences, that i t i s d i f f i c u l t to obtain clear, precise concepts of the attitudes that are uppermost i n t h e i r relationships with the c h i l d , and how these attitudes are expressed i n t h e i r day-to-day contact with him. Nevertheless, i f diagnosis i s to be as accurate as possible, a more e x p l i c i t assessment of basic parental attitudes i s e s s e n t i a l . In some instances i t may not be possible to obtain t h i s in a one-to-one interview and, i n such cases, a home v i s i t or family interview may be indicated i f the family i s ready and w i l l i n g to p a r t i c i p a t e i n such a plan. Some parents may be too f e a r f u l to permit such exploration i n the e a r l y stages of contact; where t h i s s i t u a t i o n exists more time i s required to b u i l d a t r u s t i n g r e l a t i o n s h i p between the s o c i a l worker and the family before a diagnosis can be made. Whatever methods are chosen, within the casework p r i n c i p l e s of respect and concern f o r i n d i v i d u a l family members, the goal of obtaining as complete an understanding as possible of parental attitudes towards the c h i l d i s of the utmost importance. This point needs emphasizing because i t was not clear from some of the records that workers were attempting to evaluate how the mother and father did f e e l towards t h e i r problem c h i l d . Some of the h i s t o r i e s tend to give an excel-lent picture of parents' past circumstances, feelings and 64 behaviour without, however, relating these factors to current attitudes towards the ch i ld . One may conjecture that a mother, who has had a poor relationship with her own father, may feel hostile towards the chi ld who reminds her of him, but this remains only conjecture unless this hypo-thesis is tested. Many of the decisions made in the area of family relationships in Schedule B were of necessity, some-what arbitrary. From the information obtained on mother-child relationships, none of the relationships were considered to be predominantly positive, eleven were ambivalent, six were described as basical ly negative, while there was insufficient information on three cases to make a decision. In father-child relationships, two were positive, seven were ambivalent, one was negative, and ten were not recorded. Of the "marital relationships 5 1 , twelve were impaired, two severely, five were not recorded, and two marriages were considered to be healthy. Generally, the connections between unsatisfactory marital and parent-child relationships were not recorded, with the result that mothers and fathers tend to be viewed f i r s t l y as i n d i -viduals, secondly as parents, and thirdly as spouses. There i s minimal exploration of their role network. This is under-standable in view of the fact that, unt i l recently, there was no conceptual framework within which to relate the very compli-cated interactions between family members. However, role theory may provide this too l , particularly the concepts of 65 reciprocal roles , the role network, and the way in which an individual 's various roles influence each other, as for example the marital and the parental roles . It is worthy of note that, of the ten cases in which the father's relat ion-ship towards the child was not recorded, seven of these cases were boys about to enter, or well advanced i n , the latency period. This i s the time in the male chi ld ' s l i f e in which much of his masculine identif ication is either strengthened or weakened; the need to include the father i s part icularly important for this age group. I f the father w i l l not participate, his resistance should be assessed to determine whether treatment w i l l enhance or threaten the family balance. In one case i t was apparent that the father's resentment about his wife and chi ld attending the Cl in ic placed additional stress on the mother's relationship with her husband, although she appeared to gain in self-under-standing through her interviews with the social worker. Such gains and losses need to be carefully weighed in terms of tota l family functioning. Regarding s ibl ings , i t was observed in some of the sample cases that, once the problem child improved, the "well-adjusted", s ibl ing began to show signs of disturbance to the extent that parents requested help for him. Harold I. is an example of th i s ; this chi ld was referred a year after his brother had been in treatment. While such requests may 66 be the parents' way of testing the worker's confidence in them, i t may also indicate that the family balance is shift ing, but the need to f ind a scape-goat within the group has remained constant. Perhaps including the "good" s ib l ing in the early stages might shorten the diagnostic and treatment time required to assist families with their relationship problems. Celia Mitchel l gives an excellent i l lu s t ra t ion of the effectiveness of early involvement of the "good" and "bad" s ib l ing . 1 1 widow with two boys, aged seven and fourteen, sought help for the older child by whom she fel t victimized because of his negative attitude towards her and the younger boy. During a family session involving a l l three members i t became apparent that the mother was displacing and carrying over strong feelings of rage which she had f e l t for her own mother onto the older boy. At the same time she exploited intimacy with the younger child who represented her unful f i l led baby se l f s t i l l craving for union with the mother. Unwittingly, this mother provoked the older boy's attacks on the younger by her obvious preference for him. The mother's recognition of the two sides of her problem made her more available for treatment, and the older boy was relieved of gui l t to find he was not the sole cause of family distress. 1 Mitche l l , Cel ia , "A Casework Approach to Disturbed Families", Exploring the Base for Family Therapy, F . 3 . A . A . , New York, 1961^ 67 Such projections on the part of parents may be revealed after several individual interviews. Family sessions early in contact, i f s k i l l f u l l y handled, may reveal more rapidly the causes of one chi ld ' s symptoms; the worker i s thus in a better position to guide the family towards the source of their problem. Furthermore, treatment is made accessible to the child who is considered well-adjusted by the parents, but who may actually be as disturbed as the child with obvious symptoms and, as Miss Mitchel l points out, the problem child is absolved of to ta l responsibil i ty for family disharmony. i Dr. Vogel and Be l l studied a small group of families with disturbed children. They compared them to healthy families and found that scapegoating of one child was common to a l l the dysfunctioning families, but was not prevalent amongst the healthy ones. They report that this pattern is not clearly revealed i f the family is treated only as a collection of separate personalities with-out some understanding of family dynamics. They suggest that the personality of the chi ld who is selected for scape-goat ing may be damaged severely unless treatment is geared towards helping the family function more adequately without needing to sacrif ice one of their members in order to maintain a balance. 1 B e l l , N.W., and Vogel, E .F . A Modern Introduction to  the Family. ? 68 Regarding s i b l i n g r e l a t i o n s h i p s , f o u r c h i l d r e n expressed ambivalence towards b r o t h e r s and s i s t e r s , seven were predominantly h o s t i l e , one c h i l d had no s i b l i n g s w h i l e e i g h t were unrecorded. In s i x cases the concepts the c h i l d communicated i n i n t e r v i e w s of h i s r e l a t i o n s h i p w i t h s i b l i n g s was d i f f e r e n t from the parents' view, w i t h t h e l a t t e r g e n e r a l l y f e e l i n g t h a t t h e r e was l e s s h o s t i l i t y than the c h i l d expressed t o the p s y c h o l o g i s t . In o n l y one case d i d the parents' and c h i l d ' s view c o i n c i d e ; w h i l e i t was i m p o s s i b l e t o compare twelve cases because of i n -s u f f i c i e n t m a t e r i a l . These r e s u l t s suggest t h a t d i a g n o s t i c m a t e r i a l r e g a r d i n g s i b l i n g r e l a t i o n s h i p s i s incomplete, which means t h a t f a m i l y d i a g n o s i s i s incomplete. Even from t h i s s m a l l sample, i t i s e v i d e n t t h a t both f a t h e r s and s i b l i n g s might be encouraged to p a r t i c i p a t e more i n the d i a g n o s t i c p e r i o d , so t h a t a f u l l e r understanding may be g a ined of i n t e r - p e r s o n a l r e l a t i o n s h i p s w i t h i n a f a m i l y and how the c h i l d ' s d i s t u r b a n c e i s r e l a t e d to f a m i l y f u n c t i o n -i n g . R e c i p r o c a l P a r e n t - C h i l d R e l a t i o n s h i p s - Comparison of t h e i r Views I t was i n t e r e s t i n g t o compare the c h i l d ' s view of h i s r e l a t i o n s h i p s w i t h par e n t s , w i t h the p a r e n t s ' views. I t i s more p o s s i b l e t o o b t a i n s p e c i f i c impressions o f the c h i l d ' s f e e l i n g s f o r h i s parents because h i s defenses are l e s s complex, and the use of p r o j e c t i v e techniques enables 69 the p s y c h o l o g i s t t o make a more d e f i n i t e e v a l u a t i o n of the c h i l d ' s a t t i t u d e s . Recording on seven of the cases suggests t h a t mother and c h i l d f e e l the same way towards each other; o f t h e seven, f o u r p a i r s i n d i c a t e ambivalence, w h i l e i n three cases the m o t h e r - c h i l d r e l a t i o n s h i p s were predominantly n e g a t i v i s t i c or withdrawn f o r bot h p a r t i c i p a n t s ; i n nine cases the mother's and c h i l d ' s views appeared d i f f e r e n t . The most p r e v a l e n t p a t t e r n t h a t emerges here i s the c h i l d ' s f e e l i n g more n e g a t i v i s t i c or withdrawn than the mother appears t o , f o r i n s i x out of the nine cases the c h i l d ' s a t t i t u d e i s d e s c r i b e d as predominantly h o s t i l e , and the mother ambivalent, w h i l e i n t h r e e cases the opp o s i t e circum-stance i s r e v e a l e d . The study o f r e c i p r o c a l r e l a t i o n s h i p s i n terms o f comparing the kinds and degrees o f f e e l i n g s evidenced by both p a r t i c i p a n t s i n a p a r e n t - c h i l d r e l a t i o n -s h i p would provide an i n t e r e s t i n g s u b j e c t f o r f u r t h e r r e s e a r c h . No c o n j e c t u r e s can be made about these d i f f e r e n c e s here s i n c e t h e r e a r e too many v a r i a b l e s to merit any h y p o t h e s i s . In the twelve cases i n which f a t h e r - c h i l d r e l a t i o n s h i p s c ould be compared, the same p a t t e r n emerges o f the c h i l d i n d i c a t i n g s t r o n g e r f e e l i n g s o f i s o l a t i o n or h o s t i l i t y i n regard to the f a t h e r than he expresses about the c h i l d . E i g h t o f the cases d i d not r e c o r d enough i n f o r m a t i o n about t h e f a t h e r ' s r e l a t i o n -s h i p with the c h i l d to make any comparisons. 70 R e g a r d i n g t h e p a r e n t s ' v i e w o f t h e c h i l d ' s r o l e i n t h e f a m i l y j i n e i g h t c a s e s b o t h p a r a i t s seemed t o communicate t o t h e s o c i a l w o r k e r a d e s i r e t o have t h e c h i l d t a k e h i s a p p r o p r i a t e p l a c e i n t h e f a m i l y , b u t t h e i r a m b i v a l e n t f e e l i n g s t o w a r d s h i m made i t d i f f i c u l t f o r them t o g i v e him a d e q u a t e s u p p o r t and a c c e p t a n c e t o a c h i e v e t h i s g o a l ; i n t h r e e c a s e s t h e r e i s i n s u f f i c i e n t i n f o r m a t i o n t o e v a l u a t e t h e p a r e n t s ' w i s h e s , - w h i l e i n t h e r e m a i n i n g n i n e c a s e s t h e m o t h e r s and f a t h e r s e x p r e s s d i f f e r e n t o p i n i o n s . T h i s may be i n d i c a t i v e o f e a c h p a r e n t h a v i n g c o n f l i c t i n g i d e a s r e g a r d i n g t h e c h i l d ' s p l a c e i n t h e f a m i l y , o r i t may be due t o l a c k o f c l a r i t y i n t h e r e c o r d i n g o r t h e methods o f r e s e a r c h . I f t h e f i r s t p o i n t i s r e l e v a n t , t h i s w o u l d h e l p c l a r i f y t h e e t i o l o g y o f t h e c h i l d ' s d i s t u r b a n c e , f o r c o n f l i c t i n g e x p e c t a t i o n s f r o m t h e p a r e n t s c o n f u s e t h e c h i l d and c o n t r i b u t e t o h i s i n s e c u r i t y . I n c o m p a r i n g t h e c h i l d ' s v i e w o f h i s r o l e i n t h e f a m i l y 1 w i t h t h e p a r e n t s ' v i e w , a g o od d e a l o f d i s c r e p a n c y i s f o u n d ; a l t h o u g h t h e c h i l d ' s c o n c e p t may be d i s t o r t e d o r e x a g g e r a t e d , t h i s i s n e v e r t h e l e s s t h e way he f e e l s a b o u t h i s p l a c e i n t h e f a m i l y . A v e r y s a l i e n t d i a g n o s t i c p o i n t may w e l l i n v o l v e f u r t h e r c l a r i f i c a t i o n o f t h e p a r e n t s ' a t t i t u d e s i n t h i s a r e a ; i f t h e c h i l d ' s v i e w i s d i s t o r t e d p a r e n t s must be h e l p e d t o f i n d ways o f h e l p i n g him f e e l an 1 T h i s ^ i n f o r m a t i o n was o b t a i n e d f r o m t h e p s y c h o l o g i c a l r e p o r t s . 71 important part of the family group; i f the chi ld 's concept is r e a l i s t i c , much work w i l l be required with the family to help them find healthier ways of relat ing to the ch i ld . A l l these children studied showed a marked lack of confidence and self-acceptance, which may be par t ia l ly attributed to lack of parental support in finding a satisfying place for themselves within the family group. 1 p Nuclear Family Relationships with the Extended Family <-Regarding the nuclear family's relationships with the extended family, information in the social histories was frequently very complete in the area of the parents' attitudes towards own parents, and in several instances there were expl ic i t and implicit connections made between each parents' attitudes towards his extended family and the parent-child relationship. However, fact-finding in this area may have been incomplete in terms of what actually happened between nuclear family members when the extended family created stress for them, as for example in one family where the maternal grandmother who was mentally i l l and caused the mother considerable distress. While parents' current attitudes towards se l f and the extended family, based on past experiences, are very important in gaining an 1 "nuclear family" refers to parents and their dependent children. 2 "extended family" refers to maternal and paternal re lat ives . 72 understanding of the person's functioning as a son or daughter, s ib l ing , mother or father, what continues to happen in nuclear and extended family inter-relationships is also very relevant; for these relationships are seldom static and may contribute to or detract from healthy family functioning. Since parents are seeking help for their chi ld , the way in which he i s affected and reacts to harmony or disharmony with the extended family, is of particular note. In one case the recording was very clear and connected inter-famil ia l relationship d i f f i cu l t ie s to the chi ld ' s disturbance. Family Solidarity An attempt was made to assess family sol idar i ty ; as in the other items on the schedule, three classif ications were established, which ranged from the healthy group with a strong sense of cohesiveness and family identi f icat ion, to the family experiencing persistent and severe conflict which threatened to disrupt the group. There was generally sufficient information from the social history and intake notes to evaluate family unity or disunity. There was i n -sufficient recording on only four cases; in one case the material was sufficient but was not adaptable to any one of the three categories as the parents were very closely ident i -fied with each other and shared many interests in common, but were united against the disturbed chi ld . Thirteen cases 73 f e l l within the middle group, typif ied by ambivalent relationships and inappropriate handling of conflicts and crises. These families were obviously experiencing inter-relationship d i f f i cu l t i e s , but not to the extent that continuation of the family group was threatened. Only one case f e l l in the latter-mentioned category, and one family appeared to have achieved a predominantly healthy balance. Pract ical ly a l l the families studied then have some positive t ies , have previously weathered crises without disintegrating and, by the very fact of their voluntary application, have some motivation to cope with their problems. The degree to which parents can focus on family d i f f i cu l t i e s which are contributing to the chi ld 's disturbance, rather than on the symptoms the chi ld is manifesting, w i l l depend on the emotional health inherent in each parent, as well as the professional workers' understanding of individual>and family dynamics. One aspect of family sol idarity is how the child feels about his place in the group. Thirteen children gave indications of feeling isolated, excluded or scapegoated, two fe l t somewhat accepted, none appeared to feel fu l ly loved by parents, while f ive cases were not recorded. This recal ls B e l l and Vogel's 1 studies on disturbed families 1 B e l l , N.W., and Vogel, E . F . A Modern Introduction to the .Family. 7 4 and'"' t h e i r g e n e r a l t e n d e n c y t o s e l e c t one member as t h e f o c a l p o i n t f o r u n r e s o l v e d c o n f l i c t s . I n none o f t h e sample g r o u p was t h e c o n c e p t o f t h e c h i l d ' s d i s t u r b a n c e as a r e f l e c t i o n o f p a t h o l o g y xvithin t h e t o t a l f a m i l y g r o u p e v i d e n t . Comparison o f C h i l d ' s T r e a t a b i l i t y w i t h I m p a i r m e n t i n  P a r e n t - C h i l d R e l a t i o n s h i p s T h e r e was a c o n n e c t i o n between t h e C l i n i c a l a s s e s s m e n t o f t h e c h i l d ' s c a p a c i t y f o r r e l a t i o n s h i p s , a n d t h e q u a l i t y o f h i s r e l a t i o n s h i p s w i t h p a r e n t s . S e v e n c h i l d r e n showed a d e f i n i t e c a p a c i t y f o r r e l a t i o n s h i p s ; none o f t h e p a r e n t s o f t h e s e c h i l d r e n h a d b r o u g h t o u t a b a s i c a l l y h o s t i l e a t t i t u d e t o w a r d s t h e m , a l t h o u g h t h e f a t h e r ' s a t t i t u d e i s n o t r e c o r d e d i n t h r e e c a s e s , and t h e m o t h e r ' s a t t i t u d e i s n o t n o t e d i n o n e . E i g h t c h i l d r e n were c o n s i d e r e d d i f f i c u l t t o a s s e s s r e g a r d i n g t h e i r m o t i v a t i o n f o r r e l a t i o n s h i p s . I n f i v e o f t h e s e c a s e s , p a r e n t s e x -p r e s s e d p r e d o m i n a n t l y n e g a t i v e f e e l i n g s f o r t h e c h i l d r e n i n t h i s g r o u p ; i n one c a s e b o t h p a r e n t s e x p r e s s e d a m b i v a l e n t a t t i t u d e s ; i n one case one p a r e n t was a m b i v a l e n t and t h e o t h e r p o s i t i v e . I t i s p e r h a p s s i g n i f i c a n t t h a t o f t h e s e v e n c h i l d r e n who have a good c a p a c i t y f o r r e l a t i o n s h i p s , n o t one p a r e n t i s r e c o r d e d as h a v i n g a b a s i c a l l y n e g a t i v e a t t i t u d e t o w a r d s t h e c h i l d r e n i n t h i s g r o u p , w h i l e o f t h e e i g h t c h i l d r e n whose m o t i v a t i o n f o r r e l a t i o n s h i p s i s q u e s t i o n a b l e , 75 five parents had expressed predominantly negative attitudes towards them. Two children were considered to be lacking any perceivable motivation for relationships; one of the fathers had rejected one of these children from b i r th , while thetbther youngster was an only child who was caught up in an extremely neurotic and ambivalent relationship with both parents. No recording was available on three cases as to the children's a b i l i t y to relate. These findings support the hypothesis that a chi ld ' s capacity for healthy relationships depends on the quality of his relationships with his parents. Family or Individual Focus? The casework recording in the diagnostic period i l lustrates that there i s frequently a wealth of material on the mother's background and on her concerns about the chi ld . The history of the chi ld i s generally very complete, with much pertinent material on his physical, emotional; .and mental development; possible traumatic events, such as separations from parents, serious il lnesses and accidents, and the bir th of new sibl ings , are frequently recorded. Attempts are made to interview the father at least once in the study period to obtain his view of the chi ld , and to involve him in treatment i f this is indicated and he is w i l l ing . Siblings may be observed in the waiting room i f parents happen to bring them. In these ways, a general 76 impression of each f a m i l y member's a d a p t a t i o n may be ob-t a i n e d . However, i t i s most o f t e n i n d i v i d u a l s who stand out c l e a r l y , and there i s minimal d e s c r i p t i o n of prominent pa t t e r n s o f i n t e r a c t i o n between th e mother and f a t h e r , the m o t h e r - c h i l d and f a t h e r - c h i l d p a i r s and s i b l i n g s . Casework assessments o f the v a r i o u s i n t e r - r e l a t i o n s h i p s w i t h i n a f a m i l y are not made. E v a l u a t i o n s are l a c k i n g , a l s o , o f the parents' s o c i a l f u n c t i o n i n g , so that i t becomes d i f f i c u l t to assess i f they are e x p e r i e n c i n g problems i n one p a r t i -c u l a r r o l e , or i f t h e r e are r e l a t e d areas o f impairment. Each parent's a d a p t a t i o n t o the v a r i o u s r o l e s he i s c a l l e d upon t o p l a y i s one way o f a s s e s s i n g ego s t r e n g t h s , and a l s o p r o v i d e s i n f o r m a t i o n on the c l i e n t ' s r o l e network. Sanford Sherman w r i t e s : " i f we are t o understand the i n d i v i d u a l , we must a l s o understand the s t r u c t u r e , f u n c t i o n , and v i t a l processes of the group as a d i s c r e t e system. I t i s f o r t h i s reason t h a t , i n the past decade, " f a m i l y d i a g n o s i s " has been coming to the f o r e as a focus of i n t e r e s t . " I In r e v i e w i n g the d i a g n o s t i c m a t e r i a l of the twenty sample cases, an i n d i v i d u a l , r a t h e r than a f a m i l y f o c u s , emerges. I f casework i s t o be f a m i l y - c e n t r e d , more c l a r i f i -c a t i o n i s needed on each parent's a t t i t u d e s towards the c h i l d , and how these a t t i t u d e s are expressed i n t h e i r c u r r e n t r e l a t i o n s h i p s . M a t e r i a l r e g a r d i n g the f a t h e r ' s r e l a t i o n s h i p 1 Sherman, Sanford, E x p l o r i n g the Base f o r Family Therapy. 1961, p. 18. 77 with the c h i l d i s p a r t i c u l a r l y l a c k i n g . T h i s may i n d i c a t e t h a t the m o t h e r - c h i l d r e l a t i o n s h i p i s assumed, without s u f f i c i e n t evidence, to be the most d i s t u r b e d . Connecting l i n k s are m i s s i n g between the e f f e c t s o f impaired m a r i t a l r e l a t i o n s h i p s on each p a r e n t - c h i l d p a i r , as w e l l as t h e i n f l u e n c e of parents' socio-economic s t a t u s on t h e i r f u n c t i o n -i n g as mothers and f a t h e r s . More understanding and p o s s i b l y involvement o f s i b l i n g s i s i n d i c a t e d i n the d i a g n o s t i c p e r i o d . In some cases, t h i s may be o b t a i n e d i n f a m i l y s e s s i o n s f o r through t h i s method, both v e r b a l and non-verbal ex p r e s s i o n s o f p a r e n t a l a t t i t u d e s towards c h i l d r e n , and v i c e v e r s a , may i l l u s t r a t e the r o l e s each c h i l d p l a y s , and how these r o l e s are r e l a t e d to the problem c h i l d ' s p a r t i c u l a r adjustment. There i s no i n d i c a t i o n , from the sample cases, of the concept t h a t the c h i l d ' s d i s t u r b a n c e i s a r e f l e c t i o n of pathology i n the t o t a l f a m i l y , f o r s u f f i c i e n t i n f o r m a t i o n i s not c o l l e c t e d on members' i n t e r - r e l a t i o n s h i p s t o cspe-cu-i a - t e ^ " o n the purpose h i s d i s t u r b a n c e i s s e r v i n g . I t i s r e l e v a n t t o f a m i l y d i a g n o s i s to g a i n a c l e a r e r understanding o f the i n t e r - a c t i o n of the f a m i l y group w i t h i t s community of r e s i d e n c e , f o r i n t h i s way, main c h a r a c t e r i s t i c s of t h e group's way of r e l a t i n g may be i d e n t i f i e d . Furthermore, sources of p o t e n t i a l s t r e n g t h or a d d i t i o n a l s t r e s s may be l o c a t e d . Most of the i n t e r v i e w s take p l a c e w i t h i n the C l i n i c , and i t i s l i k e l y t h a t more 78 home v i s i t s would c l a r i f y p a t t e r n s of behaviour w i t h i n the group as w e l l as w i t h the neighborhood. For the c h i l d who i s e x p e r i e n c i n g d i f f i c u l t i e s a t s c h o o l , more frequent contact between the worker, p u b l i c h e a l t h nurse and t e a c h e r i s i n d i c a t e d . In none o f the cases was a s c h o o l v i s i t r e -corded, although i n s e v e r a l i n s t a n c e s phone contacts had been made w i t h the nurse. T h i s method of communication maintains a l i a s o n between C l i n i c and s c h o o l , but does not c l a r i f y the c h i l d ' s p a r t i c u l a r problem, nor the r e s o u r c e s t h a t are a v a i l a b l e t o him, as w e l l as a f a c e - t o - f a c e i n t e r -view w i t h t h e teacher who has d a i l y c o n t a c t w i t h him. Because the p a r e n t s ' s o c i a l f u n c t i o n i n g i s not f u l l y explored, i t i s not always p o s s i b l e t o estimate what the g r e a t e s t s t r e s s e s are t h a t impinge on the p a r e n t s , and on t h e i r r e l a t i o n s h i p w i t h the d i s t u r b e d c h i l d . There may be a v e r y r e a l i s t i c problem which i s i n t e r f e r i n g w i t h the p a r e n t s ' a b i l i t y to cope w i t h t h e i r youngster. Unless many areas of f u n c t i o n i n g are e x p l o r e d , i t cannot always be assumed t h a t parents need prolonged h e l p w i t h t h e i r p a r t i -c u l a r a t t i t u d e s towards the c h i l d . Furthermore, some parents' egos may be too weak t o permit i n t e n s i v e e x p l o r a t i o n of t h e i r n e g a t i v e a t t i t u d e s , and i n such cases, help may need to be d i r e c t e d towards s u p p o r t i n g them to become more adequate i n r e l a t e d r o l e s , which may i n d i r e c t l y improve t h e i r r e l a t i o n s h i p w i t h the c h i l d . I f important areas of 79 p a r e n t s ' f u n c t i o n i n g i s known t o the caseworker, a l t e r -nate approaches t o h e l p them w i t h t h e i r a d a p t a t i o n w i l l suggest themselves. Chapter 3. FAMILY ASSESSMENT IN TREATMENT The D i a g n o s t i c Conference The f o r m a l assessment p e r i o d i n the C h i l d r e n ' s C l i n i c t e r m i n a t e s with the d i a g n o s t i c c o n f e r e n c e ; team members, who have been working w i t h the parents and c h i l d , meet t o po o l and d i s c u s s t h e i r f i n d i n g s , and t o formulate a d i a g n o s t i c a l l y - b a s e d treatment p l a n . The p s y c h i a t r i s t has g e n e r a l l y h e l d a t l e a s t one i n t e r v i e w w i t h the c h i l d and parents; these may be i n d i v i d u a l , j o i n t or f a m i l y i n t e r v i e w s , o r a combination of a l l t h r e e , depending on the o r i e n t a t i o n o f t h e p s y c h i a t r i s t . The p s y c h o l o g i s t has h e l d anywhere from one t o f i v e i n t e r v i e w s w i t h the c h i l d , although t h r e e s e s s i o n are more u s u a l . These i n t e r v i e w s are s t r u c -t u r e d around p s y c h o l o g i c a l t e s t i n g d e v i c e s ; the purpose i s t o o b t a i n as o b j e c t i v e an estimate as p o s s i b l e o f the c h i l d ' s i n t e l l e c t u a l and emotional f u n c t i o n i n g and c a p a c i t y . The s o c i a l worker may have h e l d from t h r e e t o ten (sometimes more) i n t e r v i e w s with the pare n t s , depending on the complexity o f the case and the conference s c h e d u l e . I t i s the s o c i a l worker's r o l e at these conferences t o present her view of f a m i l y f u n c t i o n i n g i n r e l a t i o n t o the c h i l d ' s problem, s a l i e n t h i s t o r i c a l f a c t o r s i n the parents* and c h i l d ' s development, and an assessment of parents* p e r s o n a l i t y 81 strengths and l imitat ions. For the sake of convenience to the team, this material is contained in the socia l history and circulated prior to conference. The social worker, in discussion with the psychiatrist and psychologist, also participates in the formulation of diagnosis and treatment goals and has carte blanche, within her area of competence, to hold different opinions from other team members on the findings and recommendations. Case Assignment Conventions According to Discipl ine in  the Children's Cl in ic Because of the staff ra t io , social workers carry the largest percentage of cases in treatment. Psychologists are assigned a few children for play therapy, because their function at the present time is largely diagnostic. Medical staff undertake some cases when the diagnosis indicates that psychiatric interviews are required; such cases may involve patients with psychosomatic problems, pre-psychotic children and adults, as well as psychotic children. Their goals may be directed towards enabling their patients to change and reorganize those aspects of their personalities which are contributing to their i l lness . Generally, however, the psychiatrist ' s treatment time is l imited by his consul-tative function. Other disciplines with special training and s k i l l s may take the same types of cases, but the main focus of the social worker's contribution should be in 82 s u p p o r t i n g and s t r e n g t h e n i n g t h e i r c l i e n t s ' defenses so t h a t they can adapt themselves more adequately t o t h e i r l i f e s i t u a t i o n s . "** C l i n i c a l Assessments o f the Sample Cases Of the twenty c h i l d r e n i n t h i s study, treatment was recommended f o r n i n e t e e n ; one c h i l d was not c o n s i d e r e d s u f f i c i e n t l y d i s t u r b e d t o need therajpy, although h i s mother r e q u i r e d p r o f e s s i o n a l h e l p . I n another case i t was questioned whether o u t - p a t i e n t treatment f o r the c h i l d was adequate. However, l a c k i n g a r e s i d e n t i a l r e s o u r c e , the c h i l d was accepted by the C l i n i c . Of the n i n e t e e n c h i l d r e n , t en were moderately d i s t u r b e d ; f o r these c h i l d r e n , s p e c i f i c areas o f maladjustment were i n d i c a t e d , but other areas were r e l a t i v e l y f r e e of d i s t u r b a n c e . A c h i l d o f t h i s type may f e e l inadequate or r e j e c t e d i n f a m i l y or peer r e l a t i o n s h i p s , but has some h e a l t h y o u t l e t s which give him a sense o f s a t i s f a c t i o n , such as s c h o l a s t i c achievement. Anne B. i s such an example; t h i s c h i l d f i n d s minimal s a t i s f a c t i o n s i n 1 I t i s the u s u a l procedure f o r a l l p r o f e s s i o n s to s c h e d u l e weekly i n - C l i n i c i n t e r v i e w s f o r t h e i r treatment cases. Excep-t i o n s t o t h i s procedure may be found i n cases of d i s t u r b e d i n d i v i d u a l s who r e q u i r e more f r e q u e n t i n t e r v i e w s , a l s o when s o c i a l workers make t h e o c c a s i o n a l home v i s i t t o parents or c h i l d r e n who, f o r a c c e p t a b l e reasons, are unable to keep t h e i r i n - o f f i c e appointments. Another e x c e p t i o n t o weekly i n t e r v i e w s i s the Day Centre program f o r c h i l d r e n , which i n v o l v e s d a i l y attendance f o r a s e l e c t e d group o f c h i l d r e n over a p e r i o d o f s e v e r a l months. 83 her r e l a t i o n s h i p s g e n e r a l l y , i s c o n s i d e r e d an e x c e l l e n t student, and i s l i k e d by her p r i n c i p a l and t e a c h e r . Seven c h i l d r e n were c o n s i d e r e d t o be d i s t u r b e d i n a l l areas, while there was i n s u f f i c i e n t r e c o r d i n g on two cases t o make an e v a l u a t i o n . Mary N. i s an example of g e n e r a l impairment; she f e e l s r e s t r i c t e d and r e j e c t e d by p a r e n t s , and does not have a c l o s e r e l a t i o n s h i p w i t h any a d u l t ; her a d a p t a t i o n a t s c h o o l i s poor, f o r she views the teacher's i n s t r u c t i o n s as f u r t h e r evidence of e x c e s s i v e demands, and i s unable t o achieve an average s t a n d i n g d e s p i t e good i n t e l l e c t u a l poten-t i a l . She f e e l s i n f e r i o r t o an o l d e r s i s t e r ; does not r e l a t e w e l l t o female peers, p r e f e r r i n g male companionship; and i s b o y i s h i n mannerisms and i n t e r e s t s . Mary i s unable to i n v e s t h e r s e l f i n any a c t i v i t y f o r l o n g . R e g r e s s i v e f e a t u r e s show up i n f r e q u e n t s o i l i n g i n c i d e n t s , and i n f e e d i n g h a b i t s . Her impairment i s severe i n both k i n d and degree. S i m i l a r l y , Norman 0. (case 13) i s c o n s i d e r e d im-p a i r e d i n a l l a r e a s , but h i s s e x u a l i d e n t i f i c a t i o n appears h e a l t h i e r and h i s r e g r e s s i o n s a r e not so severe as Mary N's. A c o r r e l a t i o n between the e x t e n t of the c h i l d ' s impairment and emotional development might have been expec-t e d , but t h i s i s not e v i d e n t and may be due to the crude-ness o f the measurement d e v i c e s . I t must be mentioned t h a t t h e r e are v a r y i n g degrees of h e a l t h and pathology i n each category, and the schedule used i n t h i s study does not p r o v i d e 84 i for the degree but rather the general areas of impair-ment. There is some correlation, however, between the re-corded negative attitudes of parents and the extent of the chi ld 's impairment. For example, of the seven children whose functioning was most disturbed, four parents (one father and three mothers) expressed predominantly negative attitudes towards them, (three unrecorded), compared to only three indications of basical ly rejecting parental attitudes, (eight unrecorded) of the ten children considered moderately disturbed. This is a s l ight correlation involv-ing many variables; further investigation would be required on these cases to determine whether the parents' negative attitudes make the most significant contributions to these children's disturbances. However, i t is generally accepted that parental attitudes do have a marked bearing on the adapt-ation of their offspring; how these feelings are expressed in their day-to-day contact with their children, and the la t ters ' response to them, would seem to be as relevant to the treatment of disturbed family members as understanding the origin of parental attitudes. It was mentioned in Chapter 2 that the day-to-day inter-action of family members might be recorded more f u l l y . SJUS Points Related to Analytical Objective of Study The analyt ical objective of this study, which is to evaluate whether the casework recording in the sample group 85 i s o r i e n t e d to the c l i e n t i n h i s f a m i l y , or whether i t i s centred i n the i n d i v i d u a l ' s emotional adjustment, has brought t o l i g h t s i x p o i n t s which, i n summary, i l l u s t r a t e the need to e s t a b l i s h more d e f i n i t e f a m i l y casework goals • and treatment methods, and i n d i c a t e some of the s t e p s t h a t are r e q u i r e d to achieve t h i s o b j e c t i v e . I t i s apparent from some of the r e c o r d s t h a t caseworkers a r e attempting to a s s i s t c l i e n t s i n d i v i d u a l l y w ith t h e i r e motional c o n f l i c t s , without connecting the a f f e c t s of these c o n f l i c t s on t h e f a m i l y r e l a t i o n s h i p s f o r which t h e y are s e e k i n g h e l p ; c o n v e r s e l y , the impact o f environmental problems on the i n d i v i d u a l does not appear to be e v a l u a t e d . The i n t e r a c t i o n of the c l i e n t w i t h h i s p a r t i c u l a r problem s i t u a t i o n becomes vague when caseworkers attempt to h e l p the i n d i v i d u a l work through such c o n f l i c t s as h o s t i l i t y towards a u t h o r i t y or a deep-seated s e x u a l problem, without r e l a t i n g such m a t e r i a l t o the p a r t i c u l a r d i f f i c u l t y at hand. I n o t h e r i n s t a n c e s , i t is. apparent t h a t the casework focus i s oriented to t h a t aspect of the c l i e n t ' s s o c i a l i n t e r a c t i o n which i s i d e n t i f i e d as the problem area. In a C h i l d Guidance C l i n i c , p a r e n t - c h i l d and m a r i t a l r e l a t i o n s h i p s , as w e l l as c l i e n t s ' r e l a t i o n -s h i p s w i t h t h e i r extended f a m i l y , comprise t h e i r major problems. The caseworker's e f f o r t s s hould t h e r e f o r e be 8 6 d i r e c t e d towards h e l p i n g her c l i e n t achieve a g r e a t e r sense of adequacy and s e c u r i t y i n these r e l a t i o n s h i p s . The s i x p o i n t s r e f e r r e d to above a r e , b r i e f l y * 1 . The need f o r a more e x p l i c i t casework e v a l u a t i o n o f parents' ego s t r e n g t h s , m o t i v a t i o n and go a l s i n f o r m u l a t i n g treatment o b j e c t i v e s ; 2 . The n e c e s s i t y t o r e c o r d problem areas which the caseworker and parents i d e n t i f y as the focus f o r treatment f o l l o w i n g the d i a g n o s t i c conference, and a t p o i n t s when these goals change; 3 . The d e s i r a b i l i t y of e s t a b l i s h i n g more d e f i n i t i v e c r i t e r i a f o r the assignment of a f a m i l y t o one worker or to two or more workers; "*" r e l a t e d t o t h i s p o i n t i s the need f o r caseworkers on shared cases t o gi v e more a t t e n t i o n t o the r e l a t i o n s h i p between t h e i r c l i e n t ' s treatment and t h a t of other f a m i l y members; 4 . More d e f i n i t i v e c r i t e r i a should be developed to determine when j o i n t and f a m i l y i n t e r v i e w i n g i s the most a p p r o p r i a t e t o enable f a m i l y members to work tog e t h e r on t h e i r r e l a t i o n -s h i p problems; 5 . D i r e c t or i n d i r e c t i n c l u s i o n o f f a m i l y members (other than the mother and the c h i l d ) i s necessary when treatment t h r e a t e n s the e q u i l i b r i u m of the f a m i l y . 6 . Caseworkers need t o become more c e r t a i n of t h e i r main f u n c t i o n , which i s to help t h e i r c l i e n t s improve t h e i r s o c i a l 1 The term " u n i t case" w i l l be used where one caseworker c a r r i e s the t o t a l f a m i l y i n treatment; "shared case" w i l l designate two or more workers assigned t o one f a m i l y . 67 f u n c t i o n i n g s . The cases which r e p o r t the g r e a t e s t improve-ment i n the problems f o r which the parents sought h e l p , focus on the i n d i v i d u a l ' s r o l e performance, and the r e c i p r o c a l : r e l a t i o n s h i p s w i t h other f a m i l y members. A word should be s a i d about the l i m i t a t i o n s of a n a l y z i n g the treatment f o c u s from the r e c o r d s a l o n e . The w r i t e r i s aware t h a t many workers are c e r t a i n of t h e i r f u n c t i o n and g i v e an e x c e l l e n t s e r v i c e without, however, r e c o r d i n g the data i n a way t h a t can be used i n t h i s study. Complete r e c o r d i n g does not always r e f l e c t the q u a l i t y o f the s e r v i c e g i v e n . However, i n a m u l t i - d i s c i p l i n e s e t t i n g , i t i s e s s e n t i a l f o r each d i s c i p l i n e t o maintain i t s own p r o f e s s i o n a l f u n c t i o n . Dr. Coleman b e l i e v e s t h a t t h i s can be accomplished only through "constant awareness, s e l f -examination and s t u d y o f procedure." 1 The study of r e c o r d -i n g i s one method t h a t can be used to determine whether casework p r a c t i c e i s compatible w i t h i t s t h e o r y . I t i s b e l i e v e d , t h e r e f o r e , t h a t more a t t e n t i o n s hould be g i v e n t o improving r e c o r d i n g p r a c t i c e s i n the C h i l d r e n ' s C l i n i c . C r i t e r i a i n Determining Casework Treatment Goals The c r i t e r i a i n use a t t h e present time t o determine the nature o f treatment and i t s probable d u r a t i o n are the 1 Coleman, J.V. , " D i s t i n g u i s h i n g Between Psychotherapy and Casework", Journal of S o c i a l Casework, V o l . 30, June, 1949, p. 251. 88 exttent of the c h i l d ' s and parents* disturbance, and the parents' m o t i v a t i o n i n seeking help. The three d i s c i p l i n e s above-mentioned p a r t i c i p a t e i n planning f o r the k i n d and > duration of treatment. Many of the p s y c h o l o g i c a l r e p o r t s i n the sample cases i n c l u d e some e v a l u a t i o n of the a c h i l d ' s a c c e s s i b i l i t y to treatment, and, i n cases where the c h i l d gave evidence of severe impairment}, the r e p o r t s s t a t e t h a t long-term treatment w i l l l i k e l y be r e q u i r e d before much improvement can be a n t i c i p a t e d . While there i s no d e f i n i t e treatment time suggested, such cases may be c a r r i e d from one t o three years i n a c t u a l p r a c t i c e . The p s y c h i a t r i s t uses the information obtained by the s o c i a l worker and the p s y c h o l o g i s t , as w e l l as h i s own i n t e r v i e w (s) w i t h the f a m i l y , as a ba s i s f o r h i s p s y c h i a t r i c assessment. I f the s o c i a l worker i s t o c a r r y the f a m i l y i n treatment, such c o n s u l t a t i o n i s i n v a l u a b l e i n planning treatment goals, f o r i t may r e l a t e the e t i o l o g y of the problems t o the p e r s o n a l i t y s t r u c t u r e s of f a m i l y members, and thus provides a broader bas i s f o r planning than a ps y c h o s o c i a l assessment alone could do. However, because the s o c i a l worker has had longer contact w i t h the parents, g e n e r a l l y she i s i n the best p o s i t i o n t o evaluate • the parents' m o t i v a t i o n f o r help , to gain an impression of 89 what they would l i k e treatment t o accomplish, and how much time and e f f o r t they are ab l e t o i n v e s t i n the pr o c e s s . Many parents s t a t e they would l i k e t h e i r c h i l d t o be "happier " , or " b e t t e r a d j u s t e d " or "more s u c c e s s f u l " f o r the c h i l d ' s own sake; how the C h i l d r e n ' s C l i n i c can h e l p i n the achievement of t h i s g o a l i s not r e c o r d e d i n t h i r t e e n of the sample cases. I t would appear t h a t the symptoms of psychopathology w i t h i n the c h i l d and h i s parents are gi v e n much c o n s i d e r a t i o n at t h e d i a g n o s t i c conference i n r e l a t i o n t o the establishment o f a treatment program f o r them. However, p a r e n t s ' ego s t r e n g t h s , m o t i v a t i o n and goals a r e not s u f f i c i e n t l y assessed i n t he r e c o r d i n g , nor r e l a t e d t o the treatment g o a l s . The r e c o r d i n g cannot always a c c u r a t e l y r e f l e c t team and c l i e n t -worker i n t e r a c t i o n and c o n c l u s i o n s , but i t i s suggested t h a t treatment goals might be re c o r d e d i n r e l a t i o n t o the problem and the f a m i l y ' s c a p a c i t y and m o t i v a t i o n t o use casework s e r v i c e s . There are no d e f i n i t i v e c r i t e r i a i n r e g a r d t o probable d u r a t i o n o f treatment a t the present time: more p r e c i s e l y f o r m u l a t e d treatment g o a l s could c o n t r i b u t e t o the es t a b l i s h m e n t of such c r i t e r i a . What f a c t o r s are needed to c l a r i f y p a r e n t s' moti-v a t i o n f o r h e l p and t h e i r e x p e c t a t i o n s of the C l i n i c ? 90 V a l u a b l e c l u e s can be found i n the problems which immed-i a t e l y p r e c i p i t a t e d t h e i r a p p l i c a t i o n f o r h e l p w i t h the d i s t u r b e d c h i l d , as w e l l as i n understanding t h e i r a t t i t u d e s towards a p s y c h i a t r i c c l i n i c , and CM the c h i l d ' s problems. These f a c t o r s should be r e l a t e d to the team's treatment goals f o r the c h i l d and h i s p a r e n t s . The f o l l o w i n g examples i l l u s t r a t e the r e s u l t s of a c c e p t i n g c h i l d r e n f o r treatment, without an adequate assessment of the parents' m o t i v a t i o n . In the case o f Freddie G., i t was a p u b l i c h e a l t h agency and not the parents who r e q u e s t e d h e l p from the C l i n i c . On s e v e r a l o c c a s i o n s , the mother s t a t e d t h a t she was a t t e n d i n g the C l i n i c because the h e a l t h agency had suggested i t , and because the C l i n i c thought her c h i l d r e q u i r e d treatment. T h i s boy's main problem appeared t o be h i s response t o h i s mother's o v e r p r o t e c t i v e n e s s , and her i n a b i l i t y to permit normal expressions of h o s t i l i t y and a g g r e s s i o n , w h i l e h i s f a t h e r encouraged him to be a "tough l i t t l e man". F r e d d i e was very r e s p o n s i v e to treatment and soon began t o b r i n g out h i s pent-up anger, f i r s t i n i n t e r v i e w s , then at home and i n the community. The mother was f e a r f u l of h i s a g g r e s s i v e behaviour and complained o f i t i n her i n t e r v i e w s , but s i n c e she c o u l d not see t h i s as h i s response t o her r i g i d demands, she c o u l d not be h e l p e d w i t h i t . When the c h i l d ' s worker l e f t t h e C l i n i c and a w a i t i n g p e r i o d was n e c e s s a r y b e f o r e he c o u l d be r e - a s s i g n e d , 91 t h e mother withdrew s i n c e her worker c o u l d not make the d e c i s i o n s f o r her as t o whether or not she s h o u l d continue, and she was unable t o make any p a r t o f t h i s d e c i s i o n h e r s e l f . While both the mother and the c h i l d responded to t h e i r workers' i n t e r e s t i n , and acceptance o f them, an a d d i t i o n a l s t r e s s was p l a c e d on the m o t h e r - c h i l d r e l a t i o n s h i p when the boy expressed h i s negative f e e l i n g s towards her; a f u l l e r e x p l o r a t i o n of the mother's m o t i v a t i o n and understanding o f c l i n i c a l treatment might have changed the f o c u s of the c h i l d ' s i n t e r v i e w s so t h a t h i s defences could have been supported u n t i l the mother c o u l d t o l e r a t e h i s h o s t i l i t y b e t t e r . I t would seem from the r e c o r d i n g t h a t t h e r e was l i t t l e o bservable improvement i n t h i s case, and the mother and c h i l d appeared t o be f u n c t i o n i n g much the same a t the end o f treatment as a t the beginn i n g . Another example where m o t i v a t i o n does not appear to have been s u f f i c i e n t l y r e l a t e d t o the treatment goals i s i n the case o f Norman 0 . , where the c h i l d , always con-s i d e r e d the w e l l - a d j u s t e d one by parents, began to show symptoms of d i s t u r b a n c e when h i s s i b l i n g improved d u r i n g treatment. The parents withdrew s h o r t l y a f t e r treatment of t h e second c h i l d was i n i t i a t e d ; i t appears t h a t they were unable to t o l e r a t e having two d i s t u r b e d c h i l d r e n , and began to r e p o r t great improvements i n both of them. But a few months l a t e r they r e - a p p l i e d , when they c o u l d no lon g e r 92 ignore the second c h i l d ' s d i s t u r b e d behaviour. I t would seem t h a t a more thorough e x p l o r a t i o n of p a r e n t s ' m o t i v a t i o n i n s e e k i n g h e l p f o r the second s i b l i n g might have r e v e a l e d t h a t they r e q u i r e d more support around t h e i r adequacy as parents before i n c l u d i n g the c h i l d i n the treatment p r o c e s s . Premature involvement and withdrawal o f a c h i l d may make him l e s s t r u s t i n g o f , and t h e r e f o r e l e s s a c c e s s i b l e t o , f u t u r e t h e r a p e u t i c r e l a t i o n s h i p s . In a l l cases where i t i s p o s s i b l e t o e v a l u a t e the outcome o f treatment, some c o r r e l a t i o n i s observable between the f a m i l y ' s use of c l i n i c a l s e r v i c e s , the p r e c i p i t a t i n g f a c t o r i n r e f e r r a l , p a r e n t a l a t t i t u d e s towards a p s y c h i a t r i c c l i n i c , and t h e i r understanding and acceptance of treatment g o a l s . S i x cases are p o s i t i v e examples of the r e l a t i o n s h i p of the above-mentioned f a c t o r s t o the outcome o f treatment; some degree of improvement i s recorded i n a l l these cases. I t f o l l o w s t h a t such f a c t o r s s h o u l d be r e c o r d e d i n each case as a b a s i s f o r d e t e r m i n i n g g o a l s , and f o r e s t i m a t i n g at l e a s t p r o v i s i o n a l l y the d u r a t i o n o f treatment needed f o r the f a m i l y ' s attainment of t h e s e g o a l s . An a d d i t i o n a l p o i n t , r e l a t e d t o parents' m o t i v a t i o n , i s the urgent need f e l t by some parents f o r c l i n i c a l s e r v i c e s . In many cases, a p p l i c a t i o n i s made at the p o i n t of g r e a t e s t s t r e s s i n the p a r e n t - c h i l d r e l a t i o n s h i p when pa r e n t s ' m o t i -93 v a t i o n i s s t r o n g e s t . Most of the p r i v a t e cases 1 t h a t are accepted tend to be judged as r e q u i r i n g long-term t r e a t -ment because of the pathology e v i d e n t i n f a m i l y members' p e r s o n a l i t i e s and r e l a t i o n s h i p s . T h i s means t h a t immediate s e r v i c e i s not u s u a l l y a v a i l a b l e t o f a m i l i e s i n c r i s e s . A r e a l i s t i c concern e x i s t s t h a t b r i e f s e r v i c e s c o u l d l e a d to s u p e r f i c i a l methods which might j e o p a r d i z e the s e r v i c e which i s a v a i l a b l e t o a s m a l l number o f f a m i l i e s . However, Howard Parad and G e r a l d Caplan 2 show t h a t i n t e r v e n t i o n can have the g r e a t e s t r e s u l t f o r the l e a s t e f f o r t when i t takes p l a c e at the h e i g h t of a f a m i l y c r i s i s , i n cases where the f a m i l y ' s pathology i s not o f a severe and l o n g - s t a n d i n g n a t u r e . I t i s p o s s i b l e t h a t more d e f i n i t e e v a l u a t i o n s of p a r e n t s ' moti-v a t i o n i n the cases t h a t are accepted c o u l d c u r t a i l the treatment time r e q u i r e d i n some i n s t a n c e s . More time would then be a v a i l a b l e f o r an emergency type o f s e r v i c e f o r f a m i l i e s i n c r i s i s whose f u n c t i o n i n g i s not b a s i c a l l y impaired. F u r t h e r c o n s i d e r a t i o n should be g i v e n to t h e develop-ment of c r i t e r i a f o r both l o n g and s h o r t - t e r m treatment. 1 P r i v a t e cases are those i n which parents apply f o r d i r e c t s e r v i c e themselves. D i a g n o s t i c s e r v i c e s a r e o f f e r e d t o f a m i l i e s who are engaged w i t h a s o c i a l or h e a l t h agency, and the r e f e r r i n g agency g e n e r a l l y c a r r i e s treatment r e s p o n s i -b i l i t i e s . 2 Parad, H.J., Caplan, G., "A Framework f o r S t u d y i n g F a m i l i e s i n C r i s e s " , S o c i a l Work, V o l . 6, No. 4 , N.A.S.W., N.Y., October, 1961. 94 Such t h i n g s as p a r e n t s ' m o t i v a t i o n and e x p e c t a t i o n , t h e i r expressed a t t i t u d e s towards the c h i l d and the extent of h e a l t h and pathology i n the f a m i l y are some o f the f a c t o r s t h a t would c o n t r i b u t e t o such c r i t e r i a . Because goals might change as treatment proceeds, these c r i t e r i a would need t o be f l e x i b l e enough t o adapt them t o each f a m i l y ' s needs. Recorded D i s c u s s i o n of Treatment Goals w i t h Parents In the sample group of twenty cases, t h e r e was i n s u f f i c i e n t i n f o r m a t i o n on two- t h i r d s of them to i n d i c a t e whether s o c i a l workers and parents had e s t a b l i s h e d goals f o r treatment. In many of these cases, the treatment pro-gram wa.s not r e f e r r e d to except to i n t e r p r e t c l i n i c a l f i n d -ings t o the pare n t s , and to arrange i n t e r v i e w s w i t h the mother and the c h i l , and i n some cases w i t h the f a t h e r . I t i s apparent from subsequent r e c o r d i n g on some o f these cases t h a t parents and s o c i a l worker are working t o g e t h e r t o achieve a common g o a l , d e s p i t e the f a c t t h a t t h i s i s not e x p l i c i t l y r e c o r d e d , while i n other cases t h e r e does not seem to be a shared purpose between the caseworker and the pa r e n t s . In o n e - t h i r d o f the sample, goals are i m p l i e d s u f f i c i e n t l y to conclude t h a t parents understood what t r e a t -ment i n v o l v e d . An attempt was made i n case 11 to e s t a b l i s h m utually compatible treatment goals between the mother and the worker, but t h i s was not adhieved, w i t h the worker 9 5 a p p a r e n t l y c o n c e n t r a t i n g too much, f o r the comfort o f the mother, on her emotional c o n f l i c t s , r e l a t e d t o her own e a r l y e x p e r i e n c e s . In case 10, the mother withdrew but r e t u r n e d b r i e f l y to another caseworker b e f o r e withdrawing permanently, and complained t h a t she had not been c l e a r on the purpose o f i n t e r v i e w s . While much of the d i f f i c u l t y can be a t t r i b u t e d t o the psychopathology o f both these mothers, i t was apparent from the r e c o r d i n g t h a t they might have been encouraged t o d e s c r i b e t h e i r own goals more f u l l y , and an attempt made e i t h e r to connect w i t h these views, t o d i s c o n -t i n u e treatment, or to t r a n s f e r the case t o another worker, on the b a s i s of insurmountable d i f f i c u l t i e s i n e s t a b l i s h i n g a common purpose f o r i n t e r v i e w s . Helen Perlman argues t h a t , when the c l i e n t has been brought p r o p e r l y i n t o a problem-s o l v i n g r e l a t i o n s h i p w i t h the agency, " t h e j c l i e n t and caseworker both know, as they c o u l d not have known otherwise, where and how they go from here. In s t r i v i n g f o r t h i s g o a l , the problem-s o l v i n g means and the pro b l e m - s o l v i n g ends are as one." 1 The case of Mrs. 3., (Case 16), i l l u s t r a t e s t h a t t h i s can be ach i e v e d . The mother became ambivalent about her c h i l d c o n t i n u i n g i n therapy; she had been d i s c u s s i n g m a r i t a l problems and wondered i f treatment f o r the c h i l d was necessa r y . However, c l i n i c a l assessment had shown Ruth 1 Perlman, H.H., S o c i a l Casework, p. 203. 96 to be a very anxious youngster who was i n need of d i r e c t therapy, and the s o c i a l worker recorded* " I mentioned th a t the c l i n i c thought the c h i l d could be helped by coming f o r i n d i v i d u a l treatment s e s s i o n s , as she i s o v e r l y f e a r f u l . I explained t h a t I thought we could help Mrs. 3 . , too, i n d i s c u s s i n g d a i l y happenings around the home, and h e l p i n g her to understand and cope w i t h f a m i l y r e a c t i o n s . I t was suggested t h a t i f there could be l e s s disagreement i n the home, i t might help the c h i l d r e n , and I wondered i f Mrs. S. w i t h a l l her strength could help Mr. 3. come i n t o the p i c t u r e more as f a r as the c h i l d r e n were concerned. We commented on the extreme r i v a l r y between the two g i r l s . " Here the s o c i a l worker i n t e r p r e t e d the recommendations to the mother i n a way she could understand; she was able t o permit the c h i l d t o remain i n therapy and both made progress. I t i s conjectured that Mrs. S. may not have been able to do t h i s without the worker's simple statement of treatment g o a l s , and t h i s would have had to l e a d to the mother's te r m i n a t i o n as w e l l . Mrs. S.'s response to the above explan-a t i o n i s not recorded, but from l a t e r e n t r i e s , i t i s apparent she connected w i t h t h i s goal h e r s e l f and was working towards i t . Summary recordings of di s c u s s i o n s on the focus of treatment between the caseworker and the c l i e n t should be inc l u d e d i n each f i l e . A format, o u t l i n i n g r e l e v a n t m a t e r i a l 97 to r e c o r d , c o u l d provide a h e l p f u l guide to the s o c i a l worker. T h i s s u g g e s t i o n i s being made because i t would help the worker and c l i e n t e x p l o r e what the focus o f treatment s h a l l be, and would a l s o p rovide a r e f e r e n c e p o i n t f o r the team's progress conferences, h e l d a p p r o x i -mately every s i x months. Such a format might i n c l u d e a summary of p a r e n t s ' responses to the f i n d i n g s , and might i s o l a t e s p e c i f i c areas of agreement and disagreementtbe-tween the c l i e n t s and the c l i n i c a l assessment, and conclude with c u r r e n t treatment o b j e c t i v e s which the c l i e n t and the worker can share. In C h i l d Guidance C l i n i c s , the focus of i n t e r v i e w s s h i f t s from time t o time because the c h i l d may be r e p r e s e n t a t i v e of one or more r e l a t e d problems i n the f a m i l y , e.g., an u n s a t i s f a c t o r y m a r i t a l r e l a t i o n s h i p , c o n f l i c t s w i t h other s i b l i n g s , d i f f i c u l t i e s w i t h the extended f a m i l y , e t c . However, i t would seem e x p e d i t i o u s to r e c o r d major s h i f t s i n treatment o b j e c t i v e s when these occur, and to e s t a b l i s h some method of making these r e a d i l y a c c e s s i b l e on the f i l e f o r the caseworkers* and teams' r e f e r e n c e , as w e l l as f o r r e -s e a r c h purposes. Helen Perlman expresses t h e s e ideas s u c c i n c t l y when she says" "The n e c e s s i t y of c l a r i f y i n g the i d e a of g o a l i n our p r a c t i c e i s d i c t a t e d by s e v e r a l c o n s i d e r a t i o n s * the caseworker's s e l f - e s t e e m and working e f f e c t i v e n e s s hinges on i t ; the content, methods and d u r a t i o n o f treatment r e l a t e t o i t ; and 9$ the a v a i l a b i l i t y of agency s e r v i c e t o a widening c l i e n t e l e depends upon i t . " 1 C r i t e r i a f o r Assignment o f Shared and U n i t Cases A c c o r d i n g to c u r r e n t p o l i c y , one s o c i a l worker i s a s s i g n e d to the f a m i l y d u r i n g the d i a g n o s t i c p e r i o d and continues, wherever f e a s i b l e , w i t h the f a m i l y as a u n i t f o l l o w i n g assessment; c o n t i n u i t y of t h e same caseworker with a f a m i l y can t h e r e f o r e be c i t e d as a c r i t e r i o n . In p r a c t i c e , however, a l a r g e r percentage o f cases are shared amongst two or more workers, Reasons f o r t h i s w i l l be e l a b o r a t e d below. In the sample, f o u r cases were c a r r i e d by one worker, t h i r t e e n cases were shared by two workers, while t h r e e were shared by t h r e e . In o n l y two cases were other d i s c i p l i n e s d i r e c t l y i n v o l v e d i n the treatment of a f a m i l y member. C o n t i n u i t y i n time i s another c r i t e r i o n which i s employed wherever p o s s i b l e . Procedures were changed i n the S o c i a l S e r v i c e Department three years ago t o end the w a i t i n g p e r i o d then i n e x i s t e n c e between the assessment and continued s e r v i c e s e c t i o n s o f the Department. Formerly, the i n t a k e worker completed the d i a g n o s t i c study and c o n t r i b u t e d t o treatment f o r m u l a t i o n s ; the case was then t r a n s f e r r e d t o the continued s e r v i c e s e c t i o n . Because t h i s system c r e a t e d a 1 Perlman, S o c i a l Casework, p. 199. 99 waiting period between the diagnostic and treatment periods, procedures were altered to provide for immediate ongoing service between these phases of a family's contact with the C l i n i c . The psychosocial and psy c h i a t r i c assessments of family members are c a r e f u l l y considered i n the assignment of cases; no established c r i t e r i a can be ci t e d i n r e l a t i o n to diagnostic considerations, however, because team members decide together whether cases are to be carried by s o c i a l workers as a family unit or shared by two or more workers, and a variety of opinions exists on t h i s subject. It may be said that the following circumstances have a bearing on the type of assignment made: 1) a c h i l d , because of his li m i t e d ego strength, may require his own therapist before he can develop a sense of t r u s t in him; he may s t i l l experience anxiety when he expresses previously prohibited feelings and ideas, but u n t i l he and his parents are able to share, understand and accept those attitudes which underlie his symptoms, he may more re a d i l y place his trust i n his own therapist without as much fear that his worker w i l l discuss his behaviour with his parents; 2) a c h i l d may need to f e e l that his therapist belongs only to him before he i s able to share him with other family members; 3) extreme disharmony and competitiveness between the parents suggest separate workers for each one; 1+) parents with very weak egos may 100 need t o have the s o l e a t t e n t i o n of t h e i r worker before they, l i k e the c h i l d , can share her w i t h other f a m i l y members; 5) extremely p o s s e s s i v e and o v e r - p r o t e c t i v e parents may f i n d g r e a t d i f f i c u l t y i n r e l a t i n g to a caseworker who i s a b l e t o e s t a b l i s h a r e l a t i o n s h i p w i t h t h e i r c h i l d and who permits behaviour which t h e y do not allow; 6) parents or c h i l d r e n , may be a s s i g n e d t o a caseworker whose sex f a c i l i t a t e s t h e i r involvement i n working on the problem-t o - b e - s o l v e d . Conversely, where the above circumstances do not e x i s t , and where th e r e i s evidence of f a m i l y u n i t y i n working towards a r e s o l u t i o n of t h e i r m utually r e c o g n i z e d problems, u n i t assignments may be made. I t should be added t h a t the i n d i v i d u a l worker's p r e f e r e n c e s have a d e f i n i t e b e a r i n g on u n i t or shared assignments. The f o r e g o i n g c r i t e r i a and s i t u a t i o n s c o n t r i b u t e to assignment d e c i s i o n s . The f o r m u l a t i o n o f more d e f i n i -t i v e c r i t e r i a i s extremely d i f f i c u l t because of the v a r y i n g needs o f each f a m i l y , and because of the d i f f e r i n g o r i e n -t a t i o n s amongst and w i t h i n the t h r e e d i s c i p l i n e s . C o l l a b o r a t i o n on Shared Cases Formal and i n f o r m a l c o n s u l t a t i o n takes p l a c e amongst s o c i a l workers s h a r i n g the same cases; casework and team conferences are f o r m a l l y s t r u c t u r e d and a r e 101 r e c o r d e d on the f i l e . A good d e a l o f the c o l l a b o r a t i o n , however, i s i n f o r m a l , and f r e q u e n t l y takes p l a c e on a weekly or bi-monthly b a s i s f o l l o w i n g i n t e r v i e w s of f a m i l y members. These i n f o r m a l conferences are not r e c o r d e d , so t h a t i t i s not p o s s i b l e t o g a i n i n f o r m a t i o n on t h e i r f r e -quency or content from the f i l e s . However, from the w r i t e r ' s own experience i n t h i s s e t t i n g , i t can be s t a t e d t h a t frequent d i s c u s s i o n s do take plac e i n which the content of i n t e r v i e w s w i t h f a m i l y members i s communicated. Such c o n s u l t a t i o n s f u r t h e r the caseworker's understanding of f a m i l y r e l a t i o n s h i p s , and a s s i s t her i n the treatment of the i n d i v i d u a l w i t h whom she i s working. T h i s c o n t r i b u t e s towards a f a m i l y f o c u s . C o l l a b o r a t i o n between caseworkers could p o s s i b l y be used i n a more s t r u c t u r e d manner w i t h c l i e n t s , however; to e l a b o r a t e , there i s l i t t l e r e f e r e n c e i n the r e c o r d e d i n t e r v i e w s s t u d i e d to i n d i c a t e t h a t d i s c u s -s i o n s are h e l d between the caseworkers and the c l i e n t s r e -g a r d i n g each i n d i v i d u a l ' s e x p e c t a t i o n s o f treatment f o r other f a m i l y members. The r e c o r d i n g suggests t h a t l i t t l e c o n s i d e r a t i o n i s g i v e n towards h e l p i n g f a m i l y members work towards s i m i l a r or complimentary g o a l s . The p r i n c i p l e of c o n f i d e n t i a l i t y may i n t e r f e r e w i t h caseworkers making c r e a t i v e use o f the i n t e r v i e w s i t u a t i o n to r e p a i r broken communication l i n e s between f a m i l y members. More thought c o u l d be g i v e n t o the connection of each i n d i v i d u a l ' s treatment w i t h t h a t of other f a m i l y members, to improve 102 communication between them, and to help them strive for common objectives. This is particularly important in working with parents who have unrealistic hopes about the results of treatment for other family members. The case of Mr. and Mrs. R. i l lustrates this point. Mrs. R. hoped that the caseworker could help her husband become less hostile with their son, and more communicative with her. The father, however, was unable to discuss these problems in his interviews, and the mother continued to expect more change in her husband's behaviour than was possible. It might have been more beneficial to help Mrs. R. accept the limitations of treatment for her husband, and to encourage her to participate in bringing about changes in their relationships herself. Problems Inherent in Unit and Shared Cases Either type of assignment presents i t s own prob-lems: practical problems in scheduling interviews are experienced with unit assignments since there are limited transportation f a c i l i t i e s to the C l i n i c , which is geogra-phically isolated from the metropolitan area. Two or three tr ips a week may be necessary for family members, or, a l ter-nately, the child and possibly his siblings may have to wait while parents are interviewed. This situation may lead to frequent disruption of parents' interviews. Professional problems arise in relation to communicating content of 103 i n t e r v i e w s between f a m i l y members, and workers may become concerned about each c l i e n t ' s r i g h t s t o c o n f i d e n t i a l i t y . T h i s i s p a r t i c u l a r l y so i n the case o f the c h i l d ; over-p r o t e c t i v e parents may f i n d great d i f f i c u l t y i n p e r m i t t i n g the c h i l d the p r i v a c y o f h i s i n t e r v i e w s , and yet they have a r i g h t t o know the worker's o p i n i o n as t o how the c h i l d i s p r o g r e s s i n g i n treatment. Furthermore, communication between f a m i l y members has f r e q u e n t l y broken down, and one o f the worker's tasks i s t o f a c i l i t a t e communication amongst them. How can t h i s be done, and a t the same time necessary p r i v a c y be maintained? These problems have tended t o o r i e n t e many s o c i a l workers towards shared cases whether or not th e r e i s enough cohesion w i t h i n a f a m i l y t o permit u n i t treatment. However, siiared cases are g e n e r a l l y more time-consuming s i n c e frequent conferences must be h e l d between the c h i l d ' s and pa r e n t s ' workers, i f they are to be kept informed o f develop-ments i n treatment. S o c i a l workers c o u l d e s t a b l i s h more d e f i n i t i v e c r i t e r i a f o r u n i t and shared assignments, and the above-mentioned problems i n h e r e n t i n u n i t cases s h o u l d be g i v e n f u r t h e r c o n s i d e r a t i o n and study. C r i t e r i a f o r I n d i v i d u a l . J o i n t and Family Interviews A) I n d i v i d u a l Interviews Most of the i n t e r v i e w s r e c o r d e d on the sample cases are i n d i v i d u a l s e s s i o n s between one c l i e n t and the caseworker; t h i s i s to be expected, s i n c e s i x t e e n of the 104 cases were shared by two or more caseworkers. The preponderance of i n d i v i d u a l i n t e r v i e w s stems from a number of causes. Caseworkers have r e c e i v e d most of t h e i r t r a i n i n g i n t h i s method and are t h e r e f o r e more knowledgable and comfortable w i t h i t ; p s y c h o a n a l y t i c t h e o r i e s and techniques have i n f l u e n c e d s o c i a l work i n r e l a t i o n t o t r a n s f e r e n c e and c o u n t e r - t r a n s f e r e n c e phenomena, which were thought to i n t e r f e r e with the establishment of a t h e r a p e u t i c r e l a t i o n s h i p i f more than one c l i e n t were i n t e r -viewed at the same time; i n d i v i d u a l i n t e r v i e w s have become customary through f o r c e of h a b i t , and caseworkers may experience a n x i e t y i n attempting group i n t e r v i e w i n g . Some of the c r i t e r i a t h a t apply to the assignment of cases on an i n d i v i d u a l b a s i s a l s o apply to the s t r u c t u r i n g of s i n g l e -c l i e n t i n t e r v i e w s , such as f a m i l y members' d i s p a r i t y i n treatment g o a l s , and c l i e n t s ' needs f o r p r i v a c y and a t t e n t i o n , before they are able to share the worker w i t h other f a m i l y members. Furthermore, no matter how f r e e and comfortable the f a m i l y may become w i t h each other, one or more of i t s members may need to spend some time i n i n d i v i d u a l i n t e r v i e w s to s o r t out a t t i t u d e s which may not be done i n the presence of other f a m i l y members. There are no d e f i n i t e c r i t e r i a f o r s t r u c t u r i n g i n d i v i d u a l i n t e r v i e w s , but r a t h e r a v a r i e t y o f c o n s i d e r a t i o n s t h a t are a p p l i e d t o each case; custom and caseworkers' p r e f e r e n c e s are a l s o i n v o l v e d . 105 B) J o i n t I n t e r v i e w s A few of the sample cases r e c o r d the o c c a s i o n a l j o i n t i n t e r v i e w between the parents and the caseworker i n the treatment p e r i o d . Two c r i t e r i a can be i d e n t i f i e d : 1) Where parents i n d i c a t e " j o i n t n e s s of purpose", t h a t i s , a w i l l i n g n e s s to v^ork t o g e t h e r on some phase of a problem; 2) Where i n d i v i d u a l i n t e r v i e w s f a i l , because each parent cannot move from a s u b j e c t i v e viewpoint to some understanding of t h e i r m a r i t a l or p a r e n t - c h i l d d i f f i c u l t i e s . The number o f j o i n t i n t e r v i e w s i n the sample i s too meagre t o draw any c o n c l u s i o n s on the e f f e c t i v e n e s s o f t h i s method, except i n the d i a g n o s t i c p e r i o d . Some of the r e c o r d i n g i n j o i n t i n t e r v i e w s d e s c r i b e d , c l e a r l y , the i n t e r -a c t i o n which took p l a c e between the mother and the f a t h e r . Even i n the treatment p e r i o d , such i n t e r v i e w s might be ex-tremely h e l p f u l i f the kinds of problems parents are exper-i e n c i n g w i t h each other are not c l e a r . P e r i o d i c j o i n t i n t e r -views might a l s o be u s e f u l t o e v a l u a t e w i t h the p a r e n t s , the gains t h a t have been made by the c h i l d and themselves, and to decide on f u t u r e treatment o b j e c t i v e s . The j o i n t i n t e r v i e w method i s one with which most caseworkers have some f a m i l i a r i t y . I t can be used as one means o f e s t a b l i s h i n g or m a i n t a i n i n g a f a m i l y focus i n casework, and c o u l d provide a b a s i s f o r f a m i l y group i n t e r -views . 106 C) Family Group Interviews While no c r i t e r i a e x i s t f o r f a m i l y group i n t e r -viewing, the S o c i a l S e r v i c e Department i n the C h i l d r e n ' s C l i n i c i s i n t e r e s t e d i n e x p l o r i n g t h i s a r e a , and i n t e s t i n g out c r i t e r i a suggested i n the l i t e r a t u r e . None o f the cases s t u d i e d recorded f a m i l y i n t e r v i e w s . S o c i a l work has been t r a d i t i o n a l l y concerned w i t h the " f a m i l y group as a whole". 1 Mary Richmond's d e s c r i p t i o n of f a m i l y groyp i n t e r v i e w i n g sounds amazingly modern. She observed t h a t caseworkers see " s e v e r a l o f the members of the f a m i l y assembled i n t h e i r home environment, a c t i n g and r e a c t i n g upon one another, each t a k i n g a share i n the develop-ment o f the c l i e n t ' s s t o r y , each r e v e a l i n g i n ways other than words s o c i a l f a c t s of r e a l s i g n i f i c a n c e . " F a m i l y i n t e r v i e w i n g today takes cognizance of p s y c h o l o g i c a l , as w e l l as s o c i a l , f a c t o r s . To the knowledge o f the f a m i l y as a s o c i a l , c u l t u r a l and economic group, an understanding of unconscious processes, ego f u n c t i o n i n g and r o l e performance has been added. Frances H. Scherz 3 suggests c r i t e r i a f o r the use of m u l t i - c l i e n t i n t e r v i e w i n g , and c o n t r a i n d i c a t i o n s to such 1 Richmond, Mary E., S o c i a l D i a g n o s i s . R u s s e l l Sage Found-a t i o n , New York, 1917, p. 15. 2 I b i d . , p. 134. 3 Scherz, F.H., " M u l t i - C l i e n t I n t e r v i e w i n g : I m p l i c a t i o n s " , J o u r n a l of S o c i a l Casework, V o l . 43, J u l y , 1961. 107 a method. In her o p i n i o n , such i n t e r v i e w s are e f f e c t i v e w i t h : 1) a c t i n g - o u t c h a r a c t e r d i s o r d e r s w i t h t h e i r major problems i n the area o f f a m i l y r e l a t i o n s h i p s , and when the f i r s t g o a l i n treatment i s to h e l p them examine t h e i r r o l e behaviour. C h i l d r e n may be i n c l u d e d i n i n t e r v i e w s a f t e r the m a r i t a l p a r t n e r s have made some progress i n understanding t h e i r r e s p e c t i v e r o l e s , and are able t o behave c o n s t r u c t i v e l y towards each other; 2) n e u r o t i c parents of phobic c h i l d r e n . Frances Sherz w r i t e s , "We have found t h a t , i n some i n s t a n c e s , the h o s t i l e - d e p e n d e n t t i e between mother and c h i l d i s loosened more r e a d i l y when the parents are f i r s t t r e a t e d through j o i n t i n t e r v i e w s . " "*"; 3) f a m i l i e s i n which the c r u c i a l problem i s the c h r o n i c i l l n e s s of one of i t s members, and where the i n i t i a l treatment g o a l i s one o f f u r t h e r i n g f a m i l y members' understanding o f the nature o f the disablement, and of r e -ducing t h e i r g u i l t ; 4) f a m i l i e s t h a t can t o l e r a t e the a n x i e t y of working on t h e i r problems w i t h each other, and where the f i r s t treatment aim i s to h e l p f a m i l y members improve t h e i r r o l e f u n c t i o n i n g and t h e i r p a t t e r n s o f communi-c a t i o n . "When the p a r t i c i p a n t s work to g e t h e r as f a m i l y members who share a mutual r e s p o n s i b i l i t y , impetus i s given to the process o f working out o f the most acute and h u r t f u l problems." 2 5) Parents who are unable t o cope s i m u l t a n e o u s l y 1 Scherz, J o u r n a l o f S o c i a l Casework, p. 122. 2 Loc. c i t . ' 108 w i t h both t h e i r own and t h e i r c h i l d ' s problems, but may-be able t o respond t o an approach t h a t emphasizes t h e i r h a n d l i n g o f the c h i l d ; 6 ) c e r t a i n c h a o t i c f a m i l y s i t u -a t i o n s i n which order has to be i n t r o d u c e d , and where i n d i v i d u a l f a m i l y members f e e l overwhelmed by the complexity of the problems. The s i x s i t u a t i o n s o u t l i n e d above a l l have p o t e n t i a l f o r a d a p t a t i o n t o C h i l d Guidance p r a c t i c e . I t i s worth n o t i n g t h a t the author conceives of f a m i l y i n t e r v i e w i n g o n l y i n r e l a t i o n t o a f a m i l y ' s r e a d i n e s s t o p r o f i t from t h i s method. She a l s o b e l i e v e s t h a t m u l t i - c l i e n t i n t e r -views should be i n t e r s p e r s e d w i t h i n d i v i d u a l i n t e r v i e w s , where i n d i c a t e d , and w i t h the same caseworker. T h i s could present many problems to the worker, p a r t i c u l a r l y i n the area o f e s t a b l i s h i n g a c o n s i s t e n t r e l a t i o n s h i p and focus w i t h the c l i e n t alone, and i n the f a m i l y group. T h o u g h t f u l experimentation would e i t h e r confirm or r e f u t e whether both i n d i v i d u a l and group i n t e r v i e w i n g methods could be c a r r i e d out by the same caseworker. Miss Scherz o u t l i n e s f o u r s i t u a t i o n s where f a m i l y i n t e r v i e w i n g i s c o n t r a i n d i c a t e d . One i s when f a m i l y members are motivated to support, p r i m a r i l y , each o t h e r ' s d e s t r u c t i v e defenses. The second i s when the d i s t u r b a n c e o f one f a m i l y member produces the c r u c i a l f a m i l y c o n f l i c t t o which other 1 0 9 i n d i v i d u a l s are r e a c t i n g . A t h i r d s i t u a t i o n i s when an i n d i v i d u a l i s overwhelmed by i n t r a p e r s o n a l a n x i e t y , or i s e x c e s s i v e l y f e a r f u l of r e v e a l i n g h i m s e l f t o other f a m i l y members, and a f o u r t h w h e n a c l i e n t i s unable t o t o l e r a t e s h a r i n g the worker w i t h o t h e r s . In these s i t u a t i o n s , Mrs. Sherz suggests t h a t i n d i v i d u a l i n t e r v i e w s are the p r e f e r r e d treatment method. In many o f the c u r r e n t p u b l i c a t i o n s on f a m i l y i n t e r v i e w i n g , r e c o g n i t i o n i s c o n s i s t e n t l y given to the f a c t t h a t caseworkers' t r a i n i n g and experience have prepared them f o r i n d i v i d u a l and j o i n t i n t e r v i e w i n g but not f o r group s e s s i o n s ; t h e r e f o r e , c e r t a i n a n x i e t i e s and r e s i s t a n c e s may be expected as s o c i a l workers attempt t h i s new method. I t i s apparent from the above c r i t e r i a t h a t t h e r e can be no abs o l u t e answers r e g a r d i n g t i m i n g and methodology of f a m i l y s e s s i o n s but, as i n i n d i v i d u a l casework, c e r t a i n g e n e r a l p r i n c i p l e s can be formulated and adapted t o each f a m i l y ' s needs. Miss Scherz s t a t e s t h a t the f o l l o w i n g techniques have been found u s e f u l i n conducting group i n t e r v i e w s : 1 ) S i n c e the aim o f m u l t i - c l i e n t i n t e r v i e w i n g i s to f u r t h e r the understanding by the p a r t i c i p a n t s of the s i g n i f i c a n c e o f the i n t e r a c t i o n between them, any i n t e r v e n t i o n by the worker should be done i n terms of t h i s i n t e r a c t i o n . Thus the worker's i n t e r p r e t a t i o n s o f an i n d i v i d u a l ' s behaviour 1 Scherz, J o u r n a l o f S o c i a l Casework. 110 should i n d i c a t e how the p a r t i c i p a n t s are a f f e c t e d . The author i s r e f e r r i n g here to behaviour and communication t h a t e i t h e r promotes or i n t e r f e r e s with f a m i l y f u n c t i o n i n g ; 2) The worker should "occupy a p o s i t i o n o f empathic n e u t r a l i t y . He should a v o i d involvement as a r e f e r e e or i n making d e c i s i o n s f o r f a m i l y members. "The worker must concentrate not on the s p e c i f i c s of what i s b e i n g s a i d but on i t s e s s e n t i a l meaning and s i g n i f i c a n c e . " 3) The worker o f f e r s support to a l l members, does not condone the use of d e s t r u c t i v e defenses, and does not permit one member to c o n t r o l the i n t e r v i e w . 4) Non-verbal communication ought t o r e c e i v e as much o f the worker's a t t e n t i o n as v e r b a l communication; both should be d i s c u s s e d w i t h the p a r t i c i p a n t s . Thus the obvious and s u b t l e i n t e r a c t i o n s amongst f a m i l y members are brought t o t h e i r a t t e n t i o n and, once t h e y r e c o g n i z e what has happened, they can be helped l a t e r to understand i t . 5) The u l t i m a t e g o a l o f f a m i l y i n t e r v i e w i n g i s t o help the members u t i l i z e the p o t e n t i a l resources f o r understanding each ot h e r , and f o r meeting each o t h e r s ' needs. The caseworker becomes i n c r e a s -i n g l y l e s s a c t i v e as he p e r c e i v e s t h i s happening] and con-t i n u e s t o i n t e r v e n e o n l y when he can f a c i l i t a t e communication between f a m i l y members. 1 Scherz, J o u r n a l of S o c i a l Casework, p. 1 2 4 . 2 Loc. c i t • I l l I t can be seen t h a t the same techniques t h a t c o n t r i b u t e to e f f e c t i v e casework w i t h i n d i v i d u a l s may be u t i l i z e d i n f a m i l y i n t e r v i e w i n g . The e s s e n t i a l d i f f e r e n c e and c h a l l e n g e seems t o be, however, t h a t the worker i s i n a more demanding s i t u a t i o n , w i t h s e v e r a l persons r e q u i r i n g h i s support and a t t e n t i o n at the same time. T h i s f a c t o r may present a p a r t i c u l a r d i f f i c u l t y f o r s o c i a l workers i n c h i l d guidance s e t t i n g s ; much self-awareness and d i s c i p l i n e on the p a r t o f the worker f r e q u e n t l y needs to be e x e r c i s e d to a v o i d i d e n t i f y i n g w i t h the problem c h i l d who i s o f t e n misunderstood and m i s t r e a t e d , however u n w i t t i n g l y , by the parents and s i b -l i n g s . C a r e f u l study i s t h e r e f o r e r e q u i r e d t o e v a l u a t e both the f a m i l y ' s r e a d i n e s s f o r group i n t e r v i e w s and the workers* p r o f e s s i o n a l r e a d i n e s s , to provide the necessary guidance t o improve f a m i l y f u n c t i o n i n g through t h i s method. I t i s i n the a r e a of f a m i l y i n t e r v i e w i n g t h a t casework and group work might achieve some measure of i n t e -g r a t i o n . The two methods have been r a t h e r s h a r p l y separated i n s c h ools o f s o c i a l work and i n the f i e l d . Group workers, however, may be c a l l e d upon t o p r a c t i c e i n d i v i d u a l c o u n s e l -l i n g , p a r t i c u l a r l y i n Neighbourhood Houses; caseworkers are becoming more i n t e r e s t e d i n group methods as the focus o f t h e i r a t t e n t i o n expands from the i n d i v i d u a l t o the f a m i l y group. Max S i p o r i n 1 observes t h a t i n v e s t i g a t i o n i s r e q u i r e d 1 S i p o r i n , Max "Family-Centred Casework i n a P s y c h i a t r i c S e t t i n g " , S o c i a l Casework. V o l . 37, A p r i l , 1956. 112 on the r e l e v a n t group work methods and s k i l l s which could be a p p l i e d to f a m i l y - c e n t r e d treatment. He b e l i e v e s t h a t such an enquiry would b r i n g casework and group work t o -gether, and t h a t complimentary methods of h e l p to i n d i v i d u a l s and t o f a m i l y groups c o u l d be developed more e f f e c t i v e l y , through the c o l l a b o r a t i o n o f caseworkers and group workers. Involvement o f Family Members i n Treatment A) Fathers In a l l the sample cases, w i t h the exce p t i o n o f one, plans were made d u r i n g the d i a g n o s t i c conference t o i n v o l v e the c h i l d and the mother i n treatment. I t i s the C l i n i c ' s p o l i c y t o i n v o l v e both parents d u r i n g the assessment p e r i o d and, where i n d i c a t e d , t o i n c l u d e the f a t h e r i n treatment. Of the twenty cases, f i f t e e n f a t h e r s were i n v o l v e d i n treatment, while f i v e d i d not p a r t i c i p a t e . Of the former group, f i v e had r e g u l a r i n t e r v i e w s and the focus changed i n th r e e o f these cases t o the m a r i t a l r e l a t i o n s h i p , which seemed to be c r e a t i n g g r e a t e r d i f f i c u l t i e s than the p a r e n t - c h i l d r e l a t i o n s h i p . C o n s i d e r a t i o n was given i n these cases t o j o i n t i n t e r v i e w s , but the parents d i d not appear t o have enough j o i n t n e s s of purpose t o make t h i s a f e a s i b l e treatment method. Separate workers were as s i g n e d d u r i n g treatment to each parent i n two of these cases because o f pa r e n t s ' needs f o r male and female i d e n t i f i c a t i o n , and a l s o because o f the 113 s e v e r i t y o f the m a r i t a l problem and t h e i r unreadiness t o share one worker. Ten f a t h e r s were p e r i p h e r a l l y i n v o l v e d , t h a t i s , i n t e r v i e w s were o f f e r e d when the mothers i n d i c a t e d t h e i r husbands had some concern about a p a r t i c u l a r phase i n treatment. In some cases, the r e c o r d i n g s t a t e s c l e a r l y the reasons f o r the f a t h e r s ' l i m i t e d involvement; f o r example, i n case 18 both parents agreed t h a t the major problem was i n the m o t h e r - c h i l d r e l a t i o n s h i p , and the f a t h e r was i n t e r v i e w e d whenever he i n d i c a t e d , through the mother, th a t treatment was impinging on him i n a way t h a t made him anxious. S i m i l a r l y , i n case 19, the parents agreed t h a t the mo t h e r - c h i l d r e l a t i o n s h i p was the main focus o f treatment, and the f a t h e r was brought i n twice on a " r e p o r t i n g " b a s i s , and confirmed the improvement t h a t h i s wife had i n d i c a t e d i n her i n t e r v i e w s . In case 11 the r e c o r d i n g s t a t e d t h a t the f a t h e r l a c k e d m o t i v a t i o n and was not c o n s i d e r e d t o have much p o t e n t i a l s t r e n g t h i n s u p p o r t i n g the mother's and c h i l d ' s treatment; he i^as a very p a s s i v e person who seemed content t o accept whatever came a l o n g , and showed no d e s i r e to p l a y a more a c t i v e r o l e i n h i s f a m i l y . Of the f i f t e e n cases where f a t h e r s were i n c l u d e d i n the p r o c e s s , reasons can be found f o r e i t h e r t h e i r i n t e n s i v e or p e r i p h e r a l involvement w i t h the C l i n i c . The bases o f involvement vary from the team's and pa r e n t s ' mutual r e c o g n i t i o n of where the main 114 problems were l o c a t e d , to r e s i s t a n c e on the p a r t of some f a t h e r s . Whenever p o s s i b l e , r e s i s t a n t f a t h e r s should be i n v o l v e d e i t h e r d i r e c t l y , or i n d i r e c t l y , through the mother, so t h a t he may have some sense of p a r t i c i p a t i n g i n processes t h a t are a f f e c t i h g the f a m i l y . T h i s would a l s o keep the worker more informed of any changes i n the f a m i l y balance, and might h e l p the w i f e f e e l more supported by her husband. Much d i r e c t involvement may not be necessary where the mother a c t s as a communicating l i n k between the C l i n i c and her hus-band, as i n case 18. In the t r a n s f e r summary on case 19, the worker r e c o r d e d t h a t she might have i n c l u d e d the f a t h e r more as a means o f s t r e n g t h e n i n g the m a r i t a l r e l a t i o n s h i p . Of the f i v e cases where the f a t h e r s were not i n -cluded i n treatment, few comments can be l o c a t e d i n the r e -c o r d i n g t o e x p l a i n t h e i r n o n - p a r t i c i p a t i o n . In the case of B r i a n C , i t was the f a t h e r who a p p l i e d f o r h e l p w i t h the c h i l d , which i s a r a r e occurrence s i n c e i t i s u s u a l l y mothers who make the i n i t i a l r e q u e st f o r s e r v i c e . P e r s o n a l i t y i n v e s t i -g a t i o n r e v e a l e d the c h i l d ' s main d i f f i c u l t i e s were centred around h i s r e l a t i o n s h i p w i t h h i s mother; there were suggestions of a b e t t e r r e l a t i o n s h i p w i t h h i s f a t h e r , or " a t l e a s t a d e s i r e f o r i t . " 1 The f a t h e r was d e s c r i b e d as b e i n g more p a t i e n t w i t h the c h i l d than the mother, and spent much o f h i s f r e e time w i t h him. I t was d i f f i c u l t f o r the f a t h e r t o 1 Quoted from the p s y c h o l o g i c a l r e p o r t . 1 1 5 a t t e n d the C l i n i c r e g u l a r l y , because h i s employment took him away from home f o r l o n g p e r i o d s o f time. However, i n Case 1 5 , the f a t h e r was away from home f o r approximately the same amount o f time, and was a b l e to maintain f a i r l y f r e quent appointments. In case 6, the f a t h e r questioned through h i s wife whether h i s c h i l d needed treatment, but arrangements were not made f o r him to d i s c u s s t h i s q u e s t i o n w i t h the worker. P a r t of the c h i l d ' s problem, however, appeared to, stem from c o n f l i c t i n g e x p e c t a t i o n s from parents, and the f a t h e r was concerned about the mother's o v e r p r o t e c t i v e ness of which she gave evidence i n her i n t e r v i e w s . In case 1 3 , the f a t h e r d i d not t h i n k h i s c h i l d was d i s t u r b e d , but d i d q u e s t i o n h i s laxness w i t h h i s c h i l d r e n , which the mother complained about i n her i n t e r v i e w s . The f a t h e r s t a t e d h i s w i l l i n g n e s s t o co-operate, although the worker reco r d e d t h a t he was not motivated t o a t t e n d the C l i n i c on a r e g u l a r b a s i s . The impression t h i s r e c o r d i n g g i v e s i s t h a t the f a t h e r could be i n c l u d e d p e r i p h e r i a l l y , and support given t o him t o be more c o n s i s t e n t w i t h the c h i l d r e n , and to share r e s p o n s i b i l i t y f o r c h i l d - r e a r i n g w i t h h i s w i f e . S i m i l a r l y , i n case 1 4 , t h e r e i s no r e c o r d o f why the f a t h e r was not i n c l u d e d ; from the i n f o r m a t i o n given i n the s o c i a l h i s t o r y , he appeared t o be c o n s i d e r a b l y s t r o n g e r than h i s w i f e , and was able t o give her some support w i t h t h e c h i l d r e n . His w i l l i n g n e s s t o p a r t i c i p a t e i n the C l i n i c program i s r e c o r d e d . When the second c h i l d was r e f e r r e d f o r treatment, he communicated 116 through h i s wife h i s d i s s a t i s f a c t i o n with the boy m i s s i n g s c h o o l to keep C l i n i c appointments, but the r e i s no r e c o r d of the worker d i s c u s s i n g t h i s w i t h him. In case 16, the f a t h e r expressed w i l l i n g n e s s to have i n t e r v i e w s ' he rec o g -n i z e d h i s daughter's problems o f f e a r f u l n e s s , e x c i t a b i l i t y and l o n e l i n e s s , and f e l t r e s e n t f u l t h a t she d i d not co n f i d e i n him and h i s w i f e . One of the mother's main problems was her i n a b i l i t y t o share her daughters w i t h her husband, and ther e was c o n s i d e r a b l e m a r i t a l c o n f l i c t . However, d e s p i t e h i s l a c k o f involvement, the mother was helped i n bot h a r e a s . N e v e r t h e l e s s , i t i s p o s s i b l e t h a t the f a t h e r r e s e n t e d h i s non-involvement i n the treatment pr o c e s s . Lack o f data on the re c o r d s does not n e c e s s a r i l y mean t h a t the f a t h e r s ' n o n - p a r t i c i p a t i o n i n treatment was not d i a g n o s t i c a l l y based; i t may mean t h a t t h i s i n f o r m a t i o n was not r e c o r d e d . However, i f a f a m i l y focus i s t o be main-t a i n e d , i t would seem nec e s s a r y t o r e c o r d such d e c i s i o n s f o r the workers' and t h e teams" r e f e r e n c e f o r m u l a t i n g goals and i n a s s e s s i n g achievement of those g o a l s . The f o r m u l a t i o n of some p o l i c y r e g a r d i n g the f a t h e r s * involvement would support a f a m i l y f o c u s , and would guard a g a i n s t unnecessary e x c l u s i o n o f the f a t h e r i f t h i s does occur. I t i s i n t e r e s t i n g to note t h a t of the f i v e cases where the f a t h e r s are not i n c l u d e d , t h e r e does not seem t o be a r e l a t i o n s h i p between the mother's and c h i l d ' s use of treatment and the f a t h e r ' s non-117 p a r t i c i p a t i o n ; two o f these mothers r e p o r t e d improvement i n t h e i r s e l f - c o n f i d e n c e and e s t a b l i s h e d an extremely good r e -l a t i o n s h i p w i t h t h e i r workers. Two of the mothers were d i f f i -c u l t t o engage and made a p p a r e n t l y l i t t l e p r o g r e s s , while the mother wi t h two s i b l i n g s i n treatment appeared t o withdraw because of her concern about having two d i s t u r b e d c h i l d r e n . While t h i s sample i s too l i m i t e d to e s t a b l i s h any d e f i n i t e c o n c l u s i o n s , i t does suggest t h a t t h e r e are many other f a c t o r s i n a d d i t i o n t o the d i r e c t involvement o f the f a t h e r than con-t r i b u t e towards e f f e c t i v e treatment i n a C h i l d Guidance C l i n i c . B) S i b l i n g Involvement Many of the r e f e r r e d c h i l d r e n i n the sample expressed e x c e s s i v e resentment towards b r o t h e r s and s i s t e r s , and the s i b l i n g s themselves sometimes showed behaviour which was thought to be symptomatic o f d i s t u r b a n c e , such as de-manding, a t t e n t i o n - s e e k i n g conduct, and d i f f i c u l t y i n s e p a r a t i n g from t h e i r p a r e n t s . In th r e e o f the cases help was requested and g i v e n f o r a second s i b l i n g ; i n one case the mother requested s e r v i c e f o r a second c h i l d but was helped by the caseworker so t h a t r e f e r r a l became unnecessary. In t h r e e cases, the caseworkers 1 o b s e r v a t i o n s o f the s i b l i n g s i n d i c a t e t h a t treatment f o r them may have been d e s i r a b l e . T h i s i s a t o t a l o f seven out of twenty cases. As w i t h the f a t h e r s , d i r e c t involvement o f s i b l i n g s may not be necessary i f the parents can be helped w i t h t h e i r r e l a t i o n s h i p s w i t h 118 t h e i r c h i l d r e n ; however, regarding the three c h i l d r e n who were the second s i b l i n g i n each f a m i l y to be r e f e r r e d , i t i s wondered i f the treatment time r e q u i r e d by these f a m i l i e s might have been shortened by involvement of the s i b l i n g s i n the d i a g n o s t i c and p o s t - d i a g n o s t i c p e r i o d s . I t i s i n t e r e s t i n g to note that these c h i l d r e n appeared to represent the "good" side of the mothers u n t i l the d i s t u r b e d c h i l d began to improve, and i t i s p o s s i b l e that t h i s may be evaluated i n the assessment p e r i o d by the e a r l y i n c l u s i o n of these c h i l d r e n . I n such cases, c a r e f u l judgment would be re q u i r e d as t o whether parents' defenses could t o l e r a t e the p o s s i b i l i t y of r e v e a l i n g the "normal" c h i l d ' s disturbance before a t r u s t i n g r e l a t i o n s h i p had been developed w i t h the caseworker. Assessment of Treatment' Progress Conferences and Case-work Evaluations E v a l u a t i o n of treatment may be s a i d to be a c o n t i n -uing process i n s o c i a l casework through the worker's assess-ment as each case proceeds, and i n c o n s u l t a t i o n w i t h the su p e r v i s o r . Such assessments are not s p e c i f i c a l l y recorded i n most of the sample cases, however; i n some cases, the eva l u a t i o n i s i m p l i c i t i n each recorded i n t e r v i e w ; i n a few ins t a n c e s , workers' impressions of the c l i e n t ' s f u n c t i o n i n g are recorded b r i e f l y at the end of each i n t e r v i e w , while some of the cases do not assess the c l i e n t ' s f u n c t i o n i n g but 119 are descriptive of his or her conversation and behaviour. While i t is obvious in some instances that assessments are made, the absence of explicit data in the recording makes i t impossible in this type of study to evaluate progress in treatment in some of the sample cases. Progress Conferences It is the policy of the Children's Clinic to hold progress conferences on treatment cases every six months, with the f u l l team attending. Wherever possible, i t is expected that caseworkers w i l l prepare written summaries, and a format is available to assist in the compilation of this material, which provides an excellent guide for evalu-ating movement in family-focused casework. (See Appendix D). The purpose of such conferences is to evaluate families' needs and use of C l i n i c a l services and, with the help of the team, to c l a r i f y future treatment goals. In the sample group, five contained some recording on progress conferences every six months. There was record-ing on only two of these cases on both the progress conference summary and the results of the conferences. These notes were clear and precise and gave an excellent account of the caseworkers' contacts with the family in relation to original and continuing treatment goals. One progress conference was held after one year's 120 treatment i n one case; i n f i v e i n s t a n c e s , the average con-ference was one i n one-and-a-half t o two ye a r s . In nine r e c o r d s , no progress conferences are noted, although the treatment time on these cases averages twenty months. T h i s does not n e c e s s a r i l y mean t h a t conferences were not h e l d , but may s i g n i f y t h a t they were not recorded. Progress con-f e r e n c e summaries and d i s c u s s i o n p rovide an p o p p o r t u n i t y f o r the caseworker to c l a r i f y her own t h i n k i n g on cases i n r e l a t i o n t o c l i e n t s ' c l i n i c a l and p s y c h o s o c i a l diagnoses, and t h e i r aims and use of treatment. Recording o f such i n f o r m a t i o n i s v a l u a b l e f o r the worker's and team's r e f e r -ence, f o r t r a n s f e r of cases, and f o r r e s e a r c h purposes, and should t h e r e f o r e be i n c l u d e d on each f i l e . 1 Outcome o f Treatment At attempt was made to assess the improvement i n the c h i l d ' s and p a r e n t s ' f u n c t i o n i n g i n a l l cases, w i t h p a r t i c u l a r a t t e n t i o n to the c l o s e d cases. The r e c o r d e d 1 At the time of w r i t i n g , ten of the sample cases have been c l o s e d , nine are a c t i v e , w h i l e one case cannot be eva l u a t e d s i n c e the r e c o r d i n g terminates over a year ago i n m i d - t r e a t -ment, and t h e d i s p o s i t i o n i s not r e c o r d e d . The average time f o r d u r a t i o n of treatment of eigh t e e n cases i s f i f t e e n months, and f o u r t e e n months f o r the c l o s e d cases. Two cases were excluded from t h i s average; one f a m i l y withdrew f o l l o w i n g the d i a g n o s t i c assessment, and the s t a t u s of one case cannot be determined from t h e r e c o r d i n g . I n c l u s i o n o f the time spent w i t h f a m i l i e s i n the assessment p e r i o d would i n c r e a s e the average f u r t h e r by two t o three months. The average time spent t o t h i s p o i n t on the a c t i v e cases i s s i x t e e n months. I t can be seen from these f i g u r e s t h a t treatment i s g e n e r a l l y long-term; the w r i t e r t h i n k s t h a t t h i s i s a f a i r l y r e p r e s e n t a t i v e sample of the C h i l d r e n ' s C l i n i c , d i r e c t s e r v i c e cases. 121 caseworker's assessments on the families with whom they were working are used to determine movement. There i s no other'standard procedure for assessment on termination except the s o c i a l work evaluation. Other d i s c i p l i n e s could contribute more to the evaluations of progress when a family terminates.! The recording conventions i n the Children's C l i n i c c a l l for a closing summary of the family's problems, course and outcome of treatment, and reasons f o r closing. (See Appendix E) While only a t h i r d of the closed cases in the sample used t h i s format, there were s u f f i c i e n t evaluations on one family member in a l l terminated cases to draw con-clusions regarding improvement or non-improvement in family members' functioning at the end of treatment. F i f t y percent of the closed cases recorded marked improvement i n family relationships and the child's adap-ta t i o n at the end of treatment; twenty percent showed im-provement i n the child's functioning but there were s t i l l important areas of malfunctioning i n the family; twenty percent showed no improvement i n either the chil d ' s or parents' relationships and adaptation while ten percent withdrew be-fore treatment was established. The writer thought that i t might be possible to r e l a t e such factors as c l i n i c a l assess-ment of the c h i l d ' s impairment, the marital r e l a t i o n s h i p and family s o l i d a r i t y , to outcome of treatment, i n order to 122 remove some of the v a r i a b l e s hot d i r e c t l y r e l a t e d to the s e r v i c e g i v e n . However, i n s u f f i c i e n t recorded data made t h i s i m p o s s i b l e . I t must be kept i n mind t h a t the degree of impairment i n the c h i l d ' s f u n c t i o n i n g , and i n f a m i l y r e l a t i o n s h i p s , and i n the ego s t r e n g t h s of i n d i v i d u a l f a m i l y members, do have a s t r o n g b e a r i n g on whether or not f a m i l i e s are a b l e to u t i l i z e C l i n i c a l s e r v i c e s to t h e i r advantage. These f a c t o r s do l i m i t t h e f o l l o w i n g c o n c l u s i o n , and f u r t h e r r e s e a r c h i s needed to determine i t s v a l i d i t y . Of the c l o s e d cases which r e c o r d the g r e a t e s t improvement, the caseworker i n each one focused on c u r r e n t f a m i l y  r e l a t i o n s h i p s , although the p e r s o n a l i t y dynamics of i n d i v i d u a l f a m i l y members appeared from the r e c o r d i n g to be kept very much i n mind by the caseworkers. The c l i e n t s ' past e x p e r i -ences were d i s c u s s e d but were g e n e r a l l y r e l a t e d to c u r r e n t i n d i v i d u a l and f a m i l y problems. In a d d i t i o n , the c l i e n t s ' s t r e n g t h s were supported and h e a l t h y f u n c t i o n i n g was sought out as w e l l as areas of pathology. The f o l l o w i n g excerpt from one of these cases i l l u s t r a t e s the l a s t p o i n t : "Mrs. V. thought she would end up j u s t l i k e her mother,with every problem her mother had, i n c l u d i n g a r t h r i t i s . (Mrs. V s mother had been i n t e r m i t t e n t l y p s y c h o t i c s i n c e the c l i e n t ' s c h i l d -hood). I asked her t o look at h e r s e l f as an i n d i v i d u a l and to recount some of the t h i n g s she d i d w e l l ; she t h i n k s she i s a good cook, she knows she can make the f a m i l y comfortable, 123 and she makes a l l her c h i l d r e n ' s c l o t h e s . " 1 T h i s excerpt i s taken from the f i l e a f t e r s e v e r a l months of treatment; the mother had d e s c r i b e d her childhood and her f e e l i n g s about i t . Her past c o u l d not be changed, but her f u n c t i o n -i n g as a wife and mother co u l d be supported and enhanced. Another s i g n i f i c a n t p o i n t i n the cases which showed the g r e a t e s t improvement i s t h a t , i n every case except one, the r e c o r d i n g d e s c r i b e d the a c t i v i t y of the caseworker as w e l l as the c l i e n t ' s a c t i v i t y . Thus i f the caseworker strengthened defences, c l a r i f i e d a p o i n t , or encouraged i n s i g h t , the r e c o r d i n g made t h i s c l e a r . Both c l i e n t s and workers seemed c e r t a i n of t h e i r r o l e s . In case 10, which showed no improvement, a f a m i l y focus was maintained but the caseworker d i d not r e c o r d her own a c t i v i t y . The mother withdrew from treatment and r e t u r n e d b r i e f l y to another caseworker who r e c o r d e d t h a t Mrs. K. seemed confused about the purpose of i n t e r v i e w s , and appeared to f e e l t h a t she must r e p o r t on past and c u r r e n t events i n her c h i l d ' s l i f e without r e a l l y i n v o l v i n g h e r s e l f . The caseworker attempted to h e l p the mother understand the purpose of i n t e r v i e w s , but she was angry because she f e l t she had not been helped, and would not c o n t i n u e . The p s y c h i a t r i c assessment s t a t e d t h a t marked p a r a n o i d a l t r e n d s were e v i d e n t i n t h i s f a m i l y , which 1 Quoted from case 18. 124 undoubtedly c o n t r i b u t e d to the mother's i n a b i l i t y to use casework s e r v i c e s . However, the e a r l y r e c o r d i n g gives no i n d i c a t i o n t h a t the mother's i n t e r v i e w s were anything more than r e p o r t i n g s e s s i o n s . Another r e l e v a n t f a c t o r i n regard t o f a m i l y -focused treatment i s r e l a t e d t o the involvement of one or s e v e r a l f a m i l y members. In the s i x s u c c e s s f u l l y t r e a t e d cases, f i v e f a t h e r s were i n v o l v e d only p e r i p h e r a l l y , t h a t i s , they had a maximum of t e n i n t e r v i e w s during the e n t i r e course of treatment, wh i l e one f a t h e r was not i n v o l v e d d i r e c t l y at a l l . However, they were i n c l u d e d i n such a way that a f a m i l y focus was maintained; the wives were helped, where needed, w i t h t h e i r r e l a t i o n s h i p s w i t h t h e i r husbands. Furthermore, i n f i v e cases, the workers arranged i n t e r v i e w s w i t h the f a t h e r s when t h e i r concern about treatment appeared to place a d d i t i o n a l s t r e s s on them and on the mothers. I t would seem from the sample cases t h a t i n t e n s i v e involvement of f a t h e r s i n treatment i s not e s s e n t i a l i n h e l p i n g the mother and the c h i l d , provided they are included where necessary i n the treatment process. Factors which c o n t r i b u t e to the team's d e c i s i o n t o i n c l u d e the f a t h e r i n treatment are the c l i n i c a l assessment of the c h i l d ' s core problem, and the f a t h e r ' s capacity and motivation to use the s e r v i c e . I f the f a t h e r i s t o be i n v o l v e d , i t i s the caseworker's task to help him 125 s e l e c t a f o c u s which i s acce p t a b l e t o him, and which i s a l s o workable. Case 17 i l l u s t r a t e s the importance o f the focus being a c c e p t a b l e t o the f a t h e r . Mr. T.'s main problem appeared to be i n the a r e a o f male i d e n t i f i c a t i o n . He was very u n c e r t a i n of h i m s e l f i n the husband and f a t h e r r o l e s , and d i s s a t i s f i e d w i t h h i s low s t a t u s j o b . His wi f e was concerned about t h e i r poor m a r i t a l r e l a t i o n s h i p , which d i d appear t o be a major s t r e s s i n the f a m i l y to which the d i s t u r b e d c h i l d was r e a c t i n g . The f a t h e r had weekly i n t e r v i e w s f o r one year w i t h the caseworker and withdrew because he " r e s i s t e d s e e i n g h i m s e l f as a p a t i e n t . " 1 T h i s f a t h e r was i n v o l v e d i n treatment be-cause of t h e mother's concern about the marriage, and because of the C l i n i c a l assessment; h i s p a r t i c i p a t i o n was e s s e n t i a l i n s t a b i l i z i n g the f a m i l y . The caseworker devoted much thought and a t t e n t i o n t o h e l p i n g t h i s f a t h e r , but the focus which was s e l e c t e d was a p p a r e n t l y not a c c e p t a b l e to him. At the b e g i n n i n g o f treatment, Mr. T. was i n t e r e s t e d i n o b t a i n i n g v o c a t i o n a l c o u n s e l l i n g so t h a t he could f i n d employment which might o f f e r him more s a t i s f a c t i o n s . T h i s a s p e c t o f h i s male i d e n t i f i c a t i o n was not explored by the caseworker, and the i n i t i a l focus was on h i s u n s a t i s f a c t o r y s e x u a l r e l a t i o n s 1 Quoted from the casework r e c o r d i n g . 1 2 6 w i t h h i s w i f e . While communication between the parents improved t o some extent, the l a s t two e n t r i e s s t r o n g l y suggest t h a t the f a t h e r was s t i l l l o o k i n g f o r some k i n d o f v o c a t i o n a l guidance. I t i s c o n j e c t u r e d t h a t s t r e n g t h e n -i n g the f a t h e r ' s -role performance i n the area i n which he wanted help might have proved more rewarding t o Mr. T. and to the caseworker. An important p o i n t to c o n s i d e r i n i n c l u d i n g f a t h e r s i n treatment i s , t h e r e f o r e , how they can be helped t o improve t h e i r f u n c t i o n i n g as husbands and f a t h e r s . T h i s may mean that the focus w i l l be on r e l a t e d r o l e s i f the c l i e n t i s unable t o work d i r e c t l y on h i s a d a p t a t i o n as a spouse and parent. The T. case, d e s c r i b e d above, i s a good example of t h i s . I t i s r e p r e s e n t a t i v e of some of the cases s t u d i e d which concentrate on the c l i e n t ' s emotional adjustment, and do not give s u f f i c i e n t a t t e n t i o n t o oth e r f a c t o r s i n the c l i e n t ' s l i f e s i t u a t i o n . Of the nine a c t i v e cases, t h r e e showed moderate improvement i n one f a m i l y member's f u n c t i o n i n g , one showed no improvement, while no e v a l u a t i o n s are recorded on f i v e cases. Of the t h r e e cases w i t h moderate improvement, two are f a m i l y - f o c u s e d . Conclusions: Strengths and Weaknesses i n the Casework Focus H a l f the c l o s e d cases i n the sample group emphasize 127 the c l i e n t ' s s o c i a l functioning, as well as the adaptation of other family members. Fathers are included in treatment where necessary, and attention i s given to the adjustment of other than the referred c h i l d . These cases record the greatest improvement in family members' adaptation. Forty percent of the closed cases placed more emphasis on the c l i e n t ' s emotional adjustment, and record less improvement than the above-mentioned group. I t i s possible that improve-ments i n the c l i e n t ' s expressed attitudes and feelings assumed more importance in these cases, and i f so, his actual functioning would l i k e l y not be recorded and may have improved more than the f i l e s indicate. However, enhancement of the individual's adaptation to people and circumstances i n his environment i s the aim of casework services, and should therefore be given adequate attention. In order to achieve or maintain a family focus in the Children's C l i n i c , the c l i e n t must be enabled to establish r e a l i s t i c expectations of the helping process for himself and f o r other family members, and to discover goals which can be shared by other persons in his group. More attention should be given to the development of c r i t e r i a on family unit and shared cases; consideration should also be given to more extensive use of j o i n t and family interviewing as a means of f a c i l i t a t i n g involvement of family members on a common problem-to-be-worked. But most of a l l , the 128 c a s e w o r k t r e a t m e n t f u n c t i o n n e e d s d e f i n i n g . The i m p o r t a n c e o f t h i s f o r casework i n a p s y c h i a t r i c s e t t i n g h a s b een m e n t i o n e d i n some d e t a i l i n c h a p t e r one. The r e s p o n s i b i l i t y f o r d e t e r m i n i n g c a s e w o r k f o c u s and g o a l s l i e s i n two d i r e c t i o n s : t h e i n d i v i d u a l p r a c t i t i o n e r must t r y t o d e t e r m i n e what h i s f u n c t i o n i s t h r o u g h s e l e c t i n g a f o c u s w h i c h i s i n k e e p i n g w i t h s o c i a l work c o n c e p t s , a n d by p u t t i n g i t t o t h e t e s t o f e x p e r i e n c e ; i t i s t h e t a s k o f a d m i n i s t r a t i o n t o h e l p t h e w o r k e r w i t h t h i s , and t o p r o v i d e o p p o r t u n i t i e s t o d i s c u s s a n d compare c a s e w o r k " s a r e a o f competence w i t h t h a t o f p s y c h i a t r y . Chapter 4 IMPROVING THE FAMILY FOCUS The Community's Awareness of D i s t u r b e d F a m i l i e s : Resources S o c i a l agencies, m e d i c a l , l e g a l and e d u c a t i o n a l i n s t i t u t i o n s , r e l i g i o u s and r e c r e a t i o n a l o r g a n i z a t i o n s and p r i v a t e c i t i z e n s come i n t o d a i l y c o n t a c t w i t h i n d i v i d u a l s from f a m i l i e s whose f u n c t i o n i n g i s impaired from a m i l d t o a severe degree. Community concern i s expressed i n many ways about the i n c r e a s i n g d i s o r g a n i z a t i o n o f f a m i l i e s as a r e s u l t o f p e r s o n a l i t y d i f f i c u l t i e s and unhealthy s o c i a l c o n d i t i o n s . T h i s concern f i n d s e x p r e s s i o n i n the establishment and maintenance o f agencies whose f u n c t i o n s a r e to cope w i t h the v a r i o u s aspects of f a m i l y d i s o r g a n i z a t i o n . S e r v i c e s may be d i v i d e d i n t o t h r e e main c a t e g o r i e s : 1. Those which are p r e v e n t i v e ; 2. R e s t o r a t i v e s e r v i c e s ; 3» Those which help i n d i v i d u a l s from f a m i l i e s which are about t o , or have a l r e a d y , d i s i n t e g r a t e d . A g r e a t number of d i f f e r e n t agencies e x i s t s f o r each l e v e l of s e r v i c e a c c o r d i n g t o the p h y s i c a l , p s y c h o l o g i c a l , i n t e l l e c t u a l , economic and s o c i a l needs which they are e s t a b l i s h e d to s e r v e . The Community Information S e r v i c e o f t h e Gr e a t e r Vancouver Community Chest and C o u n c i l l i s t s approximately 435 g e n e r a l s e r v i c e s i n the m e t r o p o l i t a n Vancouver d i s t r i c t a l o n e ; 1 many of these o r g a n i z a t i o n s are 1 D i r e c t o r y o f Hea l t h , Welfare and R e c r e a t i o n a l S e r v i c e s i n M e t r o p o l i t a n Vancouver, Community Chest and C o u n c i l o f the Greater Vancouver Area, I960. 130 devoted to the above-mentioned goals. This gives some indicatio n of t h i s community's awareness of and concern about disturbed families. A few of these services may be thought of as preventive i n nature; r e l i g i o u s , recreational and edu-cational i n s t i t u t i o n s contribute to healthy family function-ing and are therefore preventive of family disruption. S o c i a l agencies cannot be preventive i n scope because they are established to a s s i s t with e x i s t i n g s o c i a l problems which the community has recognized. Most of t h e i r e f f o r t s are, therefore, r e s t o r a t i v e of family l i f e at the best, and, at the l e a s t , they provide for the needs of disorgan-ized f a m i l i e s . Child protection agencies are a good example of t h i s observation. S o c i a l work philosophy emphasizes that no home can replace the child's own family, but these agencies are so occupied with the r e s u l t s of family d i s i n t e g r a t i o n , that only a small part of t h e i r time can be devoted to restorative functions. Through the a i d of mass communication media, communities are becoming increasingly aware of the cost to individuals and to society of serious family breakdown. Professionals i n the mental health f i e l d have turned to the study of etiology, diagnosis and treatment of family disruption which can lead to consideration of prevention of family breakdown. 131 S o c i a l workoaction i s r e q u i r e d on two l e v e l s : 1. A more s y s t e m a t i z e d understanding of h e a l t h y and patho-l o g i c a l f a m i l y f u n c t i o n i n g ; 2. M o b i l i z a t i o n and c o - o r d i n -a t i o n of re s o u r c e s , based on s c i e n t i f i c knowledge of the f a m i l y ' s t o t a l needs t o : support and encourage h e a l t h y f a m i l y a d a p t a t i o n ; to r e s t o r e d y s f u n c t i o n i n g f a m i l i e s ; and to p r o v i d e more adequate resources f o r i n d i v i d u a l s , p a r t i -c u l a r l y f o r c h i l d r e n , whose f a m i l i e s a re unable to pr o v i d e f o r t h e i r b a s i c p h y s i c a l and emotional needs. In r e l a t i o n t o the second p o i n t , the Research Department of the Community Chest and C o u n c i l s o f Greater Vancouver r e c e n t l y conducted a survey on the a t t e n t i o n 1 North American communities are g i v i n g to the m u l t i -2 problem f a m i l y . P r e l i m i n a r y r e s u l t s of t h i s survey show t h a t over f i f t y percent o f major North American communities are g i v i n g s e r i o u s a t t e n t i o n t o t h i s problem. Such programs have taken a v a r i e t y o f forms; one i s the maintenance of agency s t r u c t u r e with more i n t e n s i v e f a m i l y - c e n t r e d case-work f o r a few of these multi-problem f a m i l i e s , w i t h v a r i o u s devices s e t up to co - o r d i n a t e the programs. Other p r o j e c t s have been e s t a b l i s h e d through community c e n t r e s ; g e n e r i c s o c i a l s e r v i c e s are o f f e r e d i n an e f f o r t t o e s t a b l i s h an 1 Communities o f 100,000 p o p u l a t i o n and over. 2 P r o p o s a l f o r an Area Demonstration P r o j e c t , May, 1962, Community Chest and C o u n c i l s f o r the Greater Vancouver a r e a . 132 i n t e g r a t e d neighbourhood approach. The most o u t s t a n d i n g of these p r o j e c t s i n North America are c i t e d as: the programs of the Community Research A s s o c i a t e s ; the S t . P a ul Family Centred P r o j e c t ; and the R e f e r r a l U n i t s and S e r v i c e s to F a m i l i e s and C h i l d r e n of the New York C i t y Youth Board. The S t . P a u l Study i s c o n s i d e r e d to be the p i o n e e r movement which has developed a methodology to diagnose and measure f a m i l y f u n c t i o n i n g and movement i n d i s o r g a n i z e d f a m i l i e s . However, t h i s and s i m i l a r p r o j e c t s have not e v a l u a t e d whether community treatment programs, which have been s e t up to promote d i s o r g a n i z e d f a m i l i e s ' s o c i a l f u n c t i o n i n g , have a c t u a l l y achieved t h e i r aim, by comparing them to a c o n t r o l group who have not r e c e i v e d such s e r v i c e s . " N e i t h e r has t h e r e been any study i n depth of the g e n e t i c , b i o l o g i c a l , p s y c h i a t r i c , p s y c h o l o g i c a l and s o c i a l f a c t o r s a s s o c i a t e d w i t h these "hard core" f a m i l i e s . " F u r t h e r , no p r o j e c t has e s t a b l i s h e d a s o c i a l s e r v i c e centre which would provide i n t e n s i v e h e a l t h , w e l f a r e and r e c r e a t i o n s e r v i c e s t o multi-problem f a m i l i e s . A s e r v i c e which i n c l u d e s some of these f a c t o r s , the Area Demonstration P r o j e c t , i s now b e i n g planned under the a u s p i c e s of the Greater Vancouver Community Chest and 1 P r o p o s a l f o r an Area Demonstration P r o j e c t , p. 5 . 133 C o u n c i l . Community i n t e r e s t i n the e s t a b l i s h m e n t o f such a p r o j e c t dates back s e v e r a l y e a r s . In 1951, d i s c u s s i o n s began between two neighbourhood houses and a f a m i l y s e r v i c e agency on the p o s s i b i l i t y of combining casework and group-work methods; t h e i r aim i n v o l v e d p r o v i s i o n of a more co-o r d i n a t e d s e r v i c e to d i s o r g a n i z e d f a m i l i e s i n contact w i t h the group work ag e n c i e s . T h i s program began i n 1955 and has now become pa r t of the r e g u l a r s e r v i c e s o f the two houses. In 1959, a r e p o r t of t h e C o - o r d i n a t i o n of S e r v i c e s Committee under the a e g i s of the S o c i a l P l a n n i n g S e c t i o n of the Chest and C o u n c i l , recommended t h a t a demonstration p r o j e c t be developed i n one area of the c i t y . In the f a l l of I960, an Agency Adv i s o r y Group, comprised o f the d i r e c t o r s of those agencies whose p a r t i c i p a t i o n was r e q u i r e d f o r such a p r o j e c t , was formed t o recommend proposals f o r t h i s e x p e r i -ment. The same year, the Research Department undertook a c h e c k l i s t survey o f multi-problem f a m i l i e s i n Vancouver c i t y , to p r o v i d e the committee w i t h d e t a i l e d i n f o r m a t i o n about the numbers and c o n c e n t r a t i o n o f these f a m i l i e s i n the community. The A d v i s o r y Committee has r e c e n t l y submitted i t s p r o p o s a l f o r the Demonstration P r o j e c t t o the Community Chest and C o u n c i l s . These proposals i n c l u d e a d m i n i s t r a t i v e s t r u c t u r e , treatment and r e s e a r c h o b j e c t i v e s , and a c a r e f u l l y planned r e s e a r c h d e s i g n . The r e p o r t s t a t e s t h a t : 134 "The uniqueness of the presen t r e s e a r c h demonstration l i e s i n t h r e e a s p e c t s * a) i t i n c o r p o r a t e s a demonstration s e r v i c e which i s a f i e l d t e s t o f experience so f a r gained from other experimental p r o j e c t s , and goes beyond t h i s i n e s t a b l i s h i n g an i n t e g r a t e d casework-group work-community o r g a n i z a t i o n approach of major p u b l i c and p r i v a t e agencies under one a d m i n i s t r a t i o n ' b) i t i n c l u d e s a c a r e f u l l y prepared c o n t r o l group type of r e s e a r c h d e s i g n , t o assess the extent t o which the r e s u l t s obtained might have occ u r r e d i n the absence of the p r o j e c t , and a f i v e - y e a r f o l l o w - u p study; c) i t i n c o r p o r a t e s a s y s t e m a t i c study of the c h a r a c t e r i s t i c s o f problem f a m i l i e s . * ' 1 The P r o j e c t ' s p r i n c i p a l treatment o b j e c t i v e s are: "the r e d u c t i o n and u l t i m a t e p r e v e n t i o n o f f a m i l y break down; the improvement of s o c i a l adjustment, w i t h consequent p o s i t i v e r e s u l t s i n f a m i l y r e l a t i o n s h i p s ; and the r e d u c t i o n of dependency." 2 T h i s r e p o r t i l l u s t r a t e s the t h o u g h t f u l n e s s and i n t e r e s t t h a t key persons i n s o c i a l agencies i n t h i s commun-i t y are t a k i n g i n the multi-problem f a m i l y . The r e p o r t makes i t c l e a r t h a t t h i s i n t e r e s t extends beyond the scope of t h e i r immediate p r o j e c t , and t h a t t h e i r u l t i m a t e aim i s the p r e v e n t i o n of f a m i l y breakdown. This p r o j e c t r e p r e s e n t s a pioneer e f f o r t i n North America i n the f i e l d of i d e n t i f y i n g f a m i l i e s ' needs, p r o v i d i n g c o - o r d i n a t e d s e r v i c e s f o r them, and a s s e s s i n g these s e r v i c e s w i t h the b e s t s c i e n t i f i c methods 1 Propo s a l f o r an Area Demonstration P r o j e c t , p. 5, 2 I b i d . , p. 4. 1 3 5 t h a t are a v a i l a b l e . As such, the Vancouver study w i l l l i k e l y make s i g n i f i c a n t c o n t r i b u t i o n s i n f a m i l y d i a g n o s i s and treatment to t h i s and other i n t e r e s t e d communities on the North American c o n t i n e n t . 1 The R e l a t i o n s h i p o f the C h i l d r e n ' s C l i n i c t o the Community Mention should be made of the C h i l d r e n ' s C l i n i c r e l a t i o n s h i p t o the community, and i t s r o l e i n the p r e v e n t i o n of f a m i l y breakdown. There i s not as much contact w i t h the community as the w r i t e r t h i n k s i s d e s i r a b l e . T h i s i s r e f l e c t e d i n the l i m i t e d s c h o o l contact i n the sample cases where l e a r n i n g d i f f i c u l t i e s i s one of the p r e s e n t i n g complaints. T h i s may be p a r t l y the r e s u l t of the C l i n i c ' s g e o g r a p h i c a l i s o l a t i o n from the m e t r o p o l i t a n area, but the method o f s t r u c t u r i n g i n d i v i d u a l c l i e n t i n - o f f i c e i n t e r v i e w s which has been p r e v a l e n t i n p s y c h i a t r i c s o c i a l work i n the l a s t two decades, has l i k e l y had c o n s i d e r a b l e i n f l u e n c e on the C l i n i c ' s detachment 2 from the community. f r 1 An i n d i c a t i o n t h a t Vancouver agencies' assessments of problems are more person-centred than f a m i l y - c e n t r e d , i s found i n the r e s u l t s of i d e n t i f i e d f a m i l y problems when two or more agencies were a c t i v e w i t h a case. There was disagreement i n 77% as t o which c o n s t e l l a t i o n o f problems were present i n the f a m i l y s i t u a t i o n . 2 An a d d i t i o n a l f a c t o r may be t h a t p s y c h i a t r i c c l i n i c s are o f t e n regarded as t r a i n i n g grounds f o r p s y c h i a t r i s t s , s o c i a l workers and c l i n i c a l p s y c h o l o g i s t s ; some protection., t h e r e -f o r e , from heavy community commitments i s r e q u i r e d i f c l i n i c a l t r a i n i n g i s to be accomplished. 136 Although s t a f f t r a i n i n g i s an important function of the Children's C l i n i c , t h i s and similar settings are committed primarily to the giving of service to the d i s -turbed c h i l d and his family who are s u f f e r i n g from psycho-l o g i c a l and s o c i a l maladaptation. Simply stated, the basic aim i s to help families l i v e r i c h e r l i v e s with each other and between t h e i r group and society, and to f i n d more s a t i s f y i n g ways of adapting to t h e i r l i f e circumstances. In order to help c l i e n t s towards t h i s goal, s o c i a l workers need to be aware of l i v i n g conditions, attitudes and events in the community that influence referred f a m i l i e s either p o s i t i v e l y or negatively. Isolation from the community makes th i s aim impossible. There is a growing professional b e l i e f that s o c i a l workers should get out of c l i n i c settings more, into the families* homes, the schools, other agencies that have worked with them, with groups of "average" parents in playschool and P.T.A. meetings, in order to f a m i l i a r i z e themselves with the r e a l i t y forces that shape and are shaped by family l i f e . This i s an ambitious and long-term plan, but a s t a r t could be made through more frequent family, school and agency contacts. Do C h i l d Guidance C l i n i c s have a role to play i n the prevention of family disorganization? The writer be-lie v e s they can and do, and perhaps more so than any other s o c i a l agency or psychiatric c l i n i c , p a r t i c u l a r l y when 137 parents apply f o r h e l p w i t h a younger c h i l d . On the b a s i s of c u r r e n t knowledge and i n f o r m a t i o n , i t i s i m p o s s i b l e to estimate how many f a m i l i e s have been r e s t o r e d to adequate f u n c t i o n i n g and i n how many, d i s i n t e g r a t i o n has been pr e -vented through the work o f t h i s C l i n i c . 1 I t has undoubtedly made c o n t r i b u t i o n s i n these a r e a s . But some way must be found t o make the s e r v i c e more a c c e s s i b l e t o f a m i l i e s at p o i n t s of s t r e s s . T h i s s e t t i n g i s an a p p r o p r i a t e one to give some l e a d e r s h i p to the community on the p r e v e n t i v e aspects of f a m i l y breakdown. Before any of these goals can be r e a l i z e d , s t r o n g a d m i n i s t r a t i v e l e a d e r s h i p from each d i s c i p l i n e , and v i t a l i n t e r e s t at e v e r y l e v e l of s t a f f and l i n e o r g a n i z a t i o n , are r e q u i r e d . The s o c i a l worker's r o l e i s one p a r t o f the t o t a l p r o c e s s , but, because o f her area of competence, and because of the advances t h a t are being made i n t h e o r y and p r a c t i c e i n the f i e l d ; caseworkers i n C h i l d Guidance C l i n i c s could make a s i g n i f i c a n t c o n t r i b u t i o n to the community i n the area of p r e v e n t i o n of f a m i l y breakdown. 1 Although s t r e n g t h e n i n g f a m i l i e s and keeping them i n t a c t i s the major aim of mental h e a l t h c l i n i c s and s o c i a l agencies, t h i s g o a l cannot always be pursued. Ex c e p t i o n s may be found where one f a m i l y member i s c h r o n i c a l l y i l l and poses a s e r i o u s t h r e a t t o the h e a l t h o f other f a m i l y members. Another e x c e p t i o n i s found where c h i l d r e n are s u f f e r i n g from severe p h y s i c a l or emotional d e p r i v a t i o n , and where the p rognosis f o r r e h a b i l i t a t i n g the parents i s poor. 1 3 8 Family Research and P r a c t i c e There i s a wealth o f r easonably sys t e m a t i z e d m a t e r i a l a v a i l a b l e on the i n d i v i d u a l ' s p e r s o n a l i t y dynamics, but s c i e n t i f i c methods o f c o n c e p t u a l i z i n g the i n d i v i d u a l ' s r e l a t i o n s h i p w i t h the f a m i l y group are s t i l l i n t h e i r i n f a n c y . Dr. Ackerman says, "...a c o n s i d e r a b l e body of e m p i r c a l o b s e r v a t i o n s concerning f a m i l y l i f e i s now a v a i l a b l e . But the u s e f u l n e s s of such knowledge i s l i m i t e d . We do not know how f a r , how a c c u r a t e l y , how s a f e l y we can g e n e r a l i z e . We have no  adequate c r i t e r i a f o r p r e d i c t i o n . Too much i s l e f t to chance, and so progress i s h i n d e r e d . " 1 What knowledge i s r e q u i r e d before the e s s e n t i a l s of f a m i l y f u n c t i o n i n g can be grasped and u t i l i z e d i n t r e a t -ment? Dr. Ackerman suggests t h a t more d e f i n i t e i n f o r m a t i o n i s r e q u i r e d on the u n i v e r s a l elements of f a m i l y l i f e , how these elements vary from c u l t u r e t o c u l t u r e , as w e l l as "a c l e a r e r d e f i n i t i o n of the dynamic i n t e r - r e l a t i o n s of 2 i n d i v i d u a l and f a m i l y group." He b e l i e v e s t h a t these f a c t s may be o b t a i n e d through r e s e a r c h and experience, p a r t i c u l a r l y through the l a t t e r medium. Whole f a m i l e s must be d e s c r i b e d , d e f i n e d , and c l a s s i f i e d "on a s i n g l e continuum, 3 r a t h e r than d e s c r i b e d as p a r t s on many cont i n u a . " A c e n t r a l c h a l l e n g e , t h e r e f o r e i s t h a t of " s e l e c t i n g the more 1 Ackerman, The Psychodynamics of F a m i l y L i f e , p. 320. ( u n d e r l i n i n g added). 2 Loc. C i t . 3 I b i d . , p. 323. 1 3 9 s i g n i f i c a n t v a r i a b l e s and r e s p e c t i n g the e s s e n t i a l i n t e r -dependence of these v a r i a b l e s . " 1 And the approach must be a h o l i s t i c - d y n a m i c one t o human behaviour r a t h e r than an a t o m i s t i c , mechanical one. The f i n a l t e s t of the v a l i d i t y of such knowledge i s the power of p r e d i c t i o n . Dr. Ackerman d i s c u s s e s the many problems i n v o l v e d i n o b t a i n i n g a c c u r a t e knowledge of f a m i l y dynamics. One i s t h a t f a m i l i e s change through time, and t h a t what h o l d s t r u e o f t h e i r dynamic i n t e r a c t i o n at one p e r i o d does not apply at another time. A f u r t h e r problem i s the matter of c o r r e c t i n t e r p r e t a t i o n o f the r e l a t i o n s of the p a r t to the whole. An a d d i t i o n a l complexity i s the p a r a d o x i c a l problem of i n j e c t i n g exactness i n t o a f i e l d of study where c l i n i c a l o b s e r v a t i o n s a r e , o f n e c e s s i t y , s u b j e c t i v e , and where the observer's presence may b r i n g about s i g n i f i c a n t changes i n f a m i l y behaviour. A f u r t h e r problem i s the p o o r l y d e f i n e d d e s c r i p t i v e terms which are used i n the f i e l d o f mental h e a l t h ; i n o r d e r t o communicate the procedures and r e s u l t s of f a m i l y s t u d i e s , concrete, s p e c i f i c , usable d e f i n i t i o n s a re r e q u i r e d , as w e l l as the need to d e f i n e c l e a r l y the bases f o r judgment i n t he an a l y s e s o f the data. There are many l e v e l s t o be con s i d e r e d : b i o l o g i c a l as opposed to s o c i a l components; h e r e d i t y as opposed to s o c i a l i z a t i o n ; t r a u m a t i c experiences i n c h i l d h o o d and adulthood and the i n d i v i d u a l ' s c a p a c i t y t o cope w i t h these e x p e r i e n c e s . 1 Ackerman, The Psychodynamics of Family L i f e , p. 3 2 3 . 140 Dr. Ackerman suggests t h a t f o u r l e v e l s o f be-h a v i o u r need to be kept i n mind i n e s t a b l i s h i n g the c o r r e l a t i o n s o f i n d i v i d u a l and f a m i l y f u n c t i o n i n g : 1) i n t r a p s y c h i c processes; 2) i n t e r a c t i o n among f a m i l y members; 3) the dynamics of the f a m i l y group as a whole; 4) the r e l a t i o n s of t h e f a m i l y w i t h the l a r g e r c u l t u r e . I t i s apparent t h a t a s i n g l e focus cannot p r o v i d e the data on f a m i l y l i f e t h a t i s r e q u i r e d ; each study would r e q u i r e hypotheses r e l a t e d t o the p a r t i c u l a r focus s e l e c t e d , and the d a t a organized a c c o r d i n g to these hypotheses. The f i n a l and i n d i s p e n s a b l e task i s t h e t e s t i n g of the f i n d i n g s , which, i f v a l i d a t e d , c o u l d c o n t r i b u t e to the d i a g n o s i s and treatment o f f a m i l y d y s f u n c t i o n i n g , and might u l t i m a t e l y promote p o s i t i v e mental h e a l t h . In order to accomplish such r e s e a r c h , Dr. Ackerman b e l i e v e s t h a t the c l i n i c i a n and the r e s e a r c h e r must j o i n f o r c e s . That s o c i a l work i s b e i n g i n f l u e n c e d by, and i n f l u e n c i n g , the c u r r e n t t r e n d towards r e s e a r c h and p r a c t i c e i n f a m i l y d i a g n o s i s and treatment i s apparent from a r t i c l e s t h a t are appearing i n c u r r e n t casework p u b l i c a t i o n s . The S t . P a u l study was extremely s i g n i f i c a n t i n t h i s r e g a r d be-cause i t underscored the need to use the t o t a l f a m i l y as the primary u n i t f o r d i a g n o s t i c study i n the p l a n n i n g and c o - o r d i n -a t i n g of community r e s o u r c e s . 1 4 1 T h i s p r o j e c t has pro v i d e d v a l u a b l e m a t e r i a l f o r s i m i l a r experiments i n community s e r v i c e s f o r d i s o r d e r e d f a m i l i e s , which has l e d t o attempts t o c l a s s i f y f a m i l i e s a c c o r d i n g t o t h e i r behaviour p a t t e r n s . Community Research A s s o c i a t e s undertook a f a m i l y c l a s s i f i c a t i o n study as a companion p i e c e of r e s e a r c h t o supplement t h r e e p r o j e c t s which were undertaken i n San Mateo, C a l i f o r n i a , Washington County, Maryland and Winona County, Minnesota. B e g i n n i n g i n 1 9 5 4 and c o n t i n u i n g f o r a p e r i o d o f t h r e e y e a r s , the purpose o f these p r o j e c t s was to experiment with procedures f o r o r g a n i z i n g community s e r v i c e s to prevent and c o n t r o l problems o f dependency, i n d i g e n t d i s a b i l i t y , and d i s o r d e r e d behaviour. A d i a g n o s t i c c l a s s i f i c a t i o n of d i s o r d e r e d f a m i l y types was thought to be i n d i s p e n s a b l e to the achievement of t h i s g o a l . C.R.A. a c c o r d i n g l y undertook a c l a s s i f i c a t i o n of d y s f u n c t i o n i n g f a m i l i e s a c c o r d i n g to t h e i r behaviour p a t t e r n s that had some d i a g n o s t i c s i g n i f i c a n c e as t o the causes and treatment of dependency, i n d i g e n t d i s a b i l i t y and d i s o r d e r e d b ehaviour. T h i s study attempted t o a r t i c u l a t e s o c i a l work concepts o f f a m i l y d i a g n o s i s w i t h i n a framework of h e a l t h y and p a t h o l o g i c a l f a m i l y f u n c t i o n i n g . C.R.A. s i f t e d out f i v e major areas of f a m i l y l i f e as a b a s i s f o r p s y c h o s o c i a l d i a g n o s i s : 1 . f a m i l y composition; 2. p s y c h o s o c i a l d i s o r d e r s and p r e c i p i t a t i n g s t r e s s present; 3 . f a m i l y s o c i a l f u n c t i o n i n g i n c l u d i n g c h i l d - r e a r i n g and 142 development, m a r i t a l adjustment and f i n a n c i a l management; 4. i n d i v i d u a l f a m i l y members" i n t e l l e c t u a l , p h y s i c a l and emotional c h a r a c t e r i s t i c s ; 5. f a m i l y of o r i g i n h i s t o r y . The concept o f pathology which was used i n t h i s study i s a r e l a t i v e one, and d i s t i n c t i o n s as t o h e a l t h and pathology are based on "which needs dominate manifest be-haviour; how many of these needs are urgent; and the be-havio u r techniques which are used i n g a i n i n g s a t i s f a c t i o n of t h e s e needs from the environment; the exaggeration and f l e x i b i l i t y o f the defenses used; which and how many f a m i l y members or others are d e p r i v e d or damaged i n the p r o c e s s . " ^ The c l a s s i f i c a t i o n system o f f a m i l i e s which C.R.A. developed i s not based on a s e r i e s o f i n t e r a c t i o n p a t t e r n s among f a m i l y members, but r a t h e r on i n t e r p e r s o n a l r e l a t i o n -s h i p p a t t e r n s a c c o r d i n g to t h e i r fundamental aims; the k i n d and response e l i c i t e d between and among f a m i l y members i s eva l u a t e d i n r e l a t i o n t o i n d i v i d u a l f a c t o r s and the s o c i a l t a sks the person may be expected to meet i n f o u r main areas which are those o f the m a r i t a l r e l a t i o n s h i p ; c h i l d r e a r i n g ; c h i l d development, and f i n a n c i a l f u n c t i o n i n g . In order of arrangement, the c l a s s e s r e p r e s e n t a continuum i n the d i r e c t i o n o f t h e f a m i l y ' s d e c r e a s i n g c a p a c i t i e s f o r mastering adaptive 1 V o i l a n d , A l i c e L., Family Casework D i a g n o s i s , Community Research A s s o c i a t e s Inc., New York, 1962, p. 9. 143 t a s k s . The f i r s t category i s t h e " p e r f e c t i o n i s t i c f a m i l y " ; the " u n s o c i a l f a m i l y " i s found at the f a r end of the con-tinuum while the "inadequate" and " e g o - c e n t r i c " f a m i l i e s occupy the m i d - p o s i t i o n s . T h i s range approximates the assessment of ego f u n c t i o n i n g o f i n d i v i d u a l s who are d e s c r i b e d as n e u r o t i c o r " c o n s c i e n c e - r i d d e n " at the upper end o f the m a t u r i t y continuum, and as p s y c h o t i c or t o t a l l y unable to f u n c t i o n s o c i a l l y a t the lower end o f the s c a l e . V a r i o u s c l a s s i f i c a t i o n s o f c h a r a c t e r d i s o r d e r s or "impulse-r i d d e n " i n d i v i d u a l s occupy p o s i t i o n s on the mid-ranee a c c o r d i n g t o t h e i r a b i l i t y to adapt themselves to t h e i r s o c i a l circumstances. Family casework may be f a c i l i t a t e d by i n c r e a s e d understanding o f each f a m i l y ' s common and unique s t r e n g t h s and l i m i t a t i o n s i n each category or mixed c l a s s i f i c a t i o n , j u s t as casework w i t h i n d i v i d u a l s has been enhanced by deeper i n s i g h t s i n t o the d i f f e r e n t i a t i o n of c l i e n t ' s p e r s o n a l i t i e s a c c o r d i n g to n e u r o t i c and c h a r a c t e r d i s o r d e r c l a s s i f i c a t i o n s . I t may be expected, however, t h a t d i a g n o s i s of the e n t i r e f a m i l y group w i l l present many more d i f f i c u l t i e s than i n d i v i d u a l assessments, which are, i n themselves, complex enough. These d i f f i c u l t i e s c ould e a s i l y l e a d to r i g i d i t y and o v e r - s i m p l i f i c a t i o n i f answers t o a l l the c o m p l e x i t i e s a re sought. There are bound to be many v a r i a t i o n s i n each f a m i l y group which must be r e s p e c t e d ; some may defy any k i n d o f deep understanding. I f t h i s p o i n t 144 i s borne i n mind, C.R.A.'s c l a s s i f i c a t i o n may provide s o c i a l work w i t h an e x c e l l e n t foundation f o r c o n c e p t u a l i z i n g f a m i l y d i a g n o s i s and treatment. These concepts are c u r r e n t l y b e i n g t e s t e d f o r t h e i r u s e f u l n e s s i n a v a r i e t y o f agency s e t t i n g s . T h i s would pr o v i d e an e x c e l l e n t r e s e a r c h p r o j e c t f o r the C h i l d r e n ' s C l i n i c . C.R.A.'s f a m i l y c l a s s i f i c a t i o n s are o u t l i n e d below. 1. The P e r f e c t i o n i s t i c Family: T h i s f a m i l y i s c h a r a c t e r -i z e d by i t s overemphasis on "good" s o c i a l conduct f o r the group; i t s g o a l s are v e r y c l e a r l y i d e n t i f i e d w i t h American c u l t u r a l v a l u e s , such as achievement, the importance o f p l a n n i n g , and r e s p o n s i b i l i t y f o r one's a c t s . What l a b e l s i t s s o c i a l f u n c t i o n i n g as p a t h o l o g i c a l i s i t s overemphasis on p e r f e c t i o n i s m i n the attainment of t l . - i r g o a l s . A) F i n a n c i a l F u n c t i o n i n g : T h i s f a m i l y manages i t s f i n a n c i a l a f f a i r s w e l l . The male wa.ge earner gets s a t i s f a c t i o n from h i s chosen work, but he may d e p r e c i a t e h i s a b i l i t i e s . B) M a r i t a l R e l a t i o n s h i p : Each p a r t n e r has a good sense of h i s and her s e x u a l i d e n t i f i c a t i o n ; good i n c e n t i v e i s found i n a t l e a s t one p a r t n e r t o work out d i f f e r e n c e s t h a t engender i n s e c u r i t y , h o s t i l i t y and f r u s t r a t i o n . M a r i t a l problems are o f t e n found i n the symptom of each spouse f e e l i n g unloved and unappreciated by the o t h e r . c) C h i l d R e a r i n g : These parents p r o v i d e good m a t e r i a l comforts f o r t h e i r c h i l d r e n , and a t l e a s t one p a r t n e r has 145 a sense of warmth f o r them. They t e a c h t h e i r o f f s p r i n g the r u l e s of s o c i a l behaviour and l i v e up to them by example. However, there i s u s u a l l y some aspect o f a p a r t i c u l a r c h i l d ' s development t h a t concerns these p a r e n t s , and they are o v e r l y -c r i t i c a l o f themselves as parents. D) C h i l d Development: C h i l d r e n from th e s e f a m i l i e s are u s u a l l y r e s p o n s i v e i n p e r s o n a l r e l a t i o n s h i p s . F r e q u e n t l y a younger c h i l d may have n e u r o t i c symptoms such as wakeful-ness, e x c e s s i v e f e a r of bed w e t t i n g e t c . In o l d e r c h i l d r e n , t here may be a mixture of p r o v o c a t i v e , e x a s p e r a t i n g behaviour and a p o s i t i v e i d e n t i f i c a t i o n w i t h the parent o f the same sex. These c h i l d r e n a ren't prone to a n t i - s o c i a l , a c t i n g - o u t be-h a v i o u r . The d i a g n o s t i c and p r o g n o s t i c i m p l i c a t i o n of what-ever symptoms appear i n the c h i l d r e n must be i n t e r p r e t e d i n r e l a t i o n to the p a r e n t s ' response, t h e i r acknowledged concern, the r e a l i s t i c steps they take to modify the s i t u a t i o n f o r the c h i l d , and t h e i r w i l l i n g n e s s to assume p a r e n t a l respon-s i b i l i t y . There w i l l be a minimum of i n t e l l e c t u a l i z a t i o n s as a defense i n p r e s e n t i n g t h e i r problems as c o n t r a s t e d to parents of the e g o - c e n t r i c f a m i l y . Parents tend t o seek help e a r l y i n the h i s t o r y o f f a m i l y d i s o r d e r s , and are able t o assume r e s p o n s i b i l i t y f o r them. I f c o r r e c t l y diagnosed, the prognosis f o r t h i s f a m i l y type i s good. 146 The Inadequate Family I This f a m i l y ' s u n d e r l y i n g c h a r a c t e r i s t i c s d e r i v e from e x c e s s i v e dependency o f each m a r i t a l p a r t n e r upon o t h e r s f o r encouragement, continued support, guidance, and help i n r e s o l v i n g problems which the average f a m i l y can manage i t -s e l f . T h i s i s u s u a l l y present i n both p a r t n e r s and s e t s the emotional tone of the f a m i l y ' s s o c i a l f u n c t i o n i n g w i t h i n the group, and w i t h the community. A) F i n a n c i a l : Fathers of these f a m i l i e s are not u s u a l l y very p l a n f u l i n a n t i c i p a t i n g the needs o f a growing f a m i l y ; they may c a r r y the p r o v i d e r r o l e but are not s t r o n g l y m o t i -vated t o achieve, and are apt to be s a t i s f i e d w i t h a mediocre wage. The w i f e seldom assumes r e s p o n s i b i l i t y f o r income pro-d u c t i o n and i s l i k e l y to experience t r o u b l e i n household management. Many o f these f a m i l i e s r e q u i r e i n t e r m i t t e n t f i n a n c i a l a i d . T h e i r f o r e s i g h t i n p l a n n i n g f o r a n t i c i p a t e d r e d u c t i o n s i n income i s meagre. B) M a r i t a l R e l a t i o n s h i p : The couple i s drawn t o g e t h e r by both wanting s a t i s f a c t i o n f o r dependency needs; t h i s assumes p a t h o l o g i c a l p r o p o r t i o n s when c h i l d r e n are born. Otherwise, the balance may be good but they have s t r o n g d r i v e s t o have c h i l d r e n . C) C h i l d R e a r i n g : They tend to have a l a r g e number of 147 c h i l d r e n , w i t h the i n f a n t or the d e f e c t i v e c h i l d having a p a r t i c u l a r appeal t o these p a r e n t s . O l d e r , normal c h i l d r e n are expected to assume a d i s p r o p o r t i o n a t e amount of respons-i b i l i t y . L i m i t e d guidance i s g i v e n to the c h i l d r e n i n be-coming s e l f - r e l i a n t . Parents r a r e l y vent t h e i r d e s t r u c t i v e impulses on t h e i r c h i l d r e n . D) C h i l d Development: The c h i l d r e n are outwardly conforming and i m i t a t i v e ; they seldom present s e r i o u s delinquency prob-lems. They are r e s t r i c t e d , however, i n forming s a t i s f a c t o r y r e l a t i o n s h i p s and i n performing s o c i a l t a s k s . These f a m i l i e s are s u s c e p t i b l e to i n t r a - f a m i l i a l d i s o r d e r s i n the a r e a o f c h i l d r e a r i n g , m a r i t a l , f i n a n c i a l , and i n d i v i d u a l d i s o r d e r s . S t r e s s i s f e l t p a r t i c u l a r l y from f i n a n c i a l and c h i l d r e a r i n g problems; the two become fu s e d , but the p a r t n e r s focus on the f i n a n c i a l d i s o r d e r s . The prognosis f o r t h i s type o f f a m i l y can be good i f a c c u r a t e l y diagnosed, and i f the agency has caseworkers w i t h the time, p a t i e n c e , and t e a c h i n g a b i l i t y r e q u i r e d f o r the r e h a b i l i t a t i o n of f a m i l y members. R e t r a i n i n g of the woman i n her w i f e and mother r o l e s i s p a r t i c u l a r l y important. The caseworker must gain t h e f a m i l y ' s confidence, and make use of the r e l a t i o n s h i p to meet the f a m i l y ' s dependency needs. She must g r a d u a l l y encourage more mature behaviour i n the v a r i o u s f u n c t i o n a l areas of f a m i l y l i f e . S y stematic 148 f o l l o w - u p i s very important with these f a m i l i e s t o c o n s o l i date g a i n s , and t o h e l p them cope w i t h new c r i s e s before they create more pathology. 3. The E g o - C e n t r i c Family The n a r c i s s i s t i c and s e l f - s e e k i n g m o t i v a t i o n s of both p a r t n e r s c o l o u r the p s y c h o s o c i a l conduct of a l l f a m i l y members. They achieve value and importance to one another o n l y as they o f f e r t o each other the o p p o r t u n i t y f o r g r a t i f i c a t i o n o f some s e l f - s e e k i n g i n t e n t i o n i n accordance w i t h t h e i r own impulses. People are important as o b j e c t s o f g r a t i f i c a t i o n r a t h e r than as i n d i v i d u a l s . A) F i n a n c i a l F u n c t i o n i n g ? Good p e r s o n a l achievement and accomplishment i s t y p i c a l o f most of the husbands. T h e i r occupations are l i k e l y t o have p r e s t i g e v a l u e s , p r e c i s i o n requirements, and o p p o r t u n i t i e s f o r e x h i b i t i o n i s m . Parent are g e n e r a l l y capable managers and are s e l f - s u f f i c i e n t i n p r a c t i c a l matters. B) M a r i t a l R e l a t i o n s h i p * P a r e n t s ' m o t i v a t i o n s f o r marriag may r e v e a l much s e l f - s e e k i n g ; t h e i r s e x u a l i d e n t i f i c a t i o n i s d i s t u r b e d . There i s a tendency towards d i v o r c e and r e -marriage which co l o u r s the c h i l d - r e a r i n g p i c t u r e . C) C h i l d - r e a r i n g i s dominated by n a r c i s s i s t i c aims. The f a m i l y type c o n s i s t s o f s i n g l e (own or adopted) c h i l d or composite o f own, adopted, and s t e p - c h i l d r e n . Although 149 e x c e l l e n t p h y s i c a l care i s g i v e n , maternal over-pro-t e c t i o n and s o l i c i t u d e r e g a r d i n g h e a l t h , e a t i n g and t r a i n -i n g i s f r e q u e n t l y p r e v a l e n t . The parents are s e d u c t i v e with t h e i r c h i l d r e n o f the opposite sex; they r e s t r i c t t h e i r o f f s p r i n g s ' s o c i a l c ontacts and t h e i r e xpressions of h o s t i l i t y towards themselves. The f a t h e r may be com-p e t i t i v e and harsh w i t h the male c h i l d r e n . Family heads set r i g i d standards of s o c i a l conduct f o r home use but may have other standards f o r behaviour o u t s i d e the home. Per-f e c t i o n i s m i n s c h o o l achievement i s demanded. D) C h i l d Development: C h i l d r e n of these f a m i l i e s have a l i m i t e d c a p a c i t y t o form s o c i a l r e l a t i o n s h i p s . They may be p r e c o c i o u s l y independent, but they may a l s o have food fads and be e x c l u s i v e l y i n t e r e s t e d i n the mother. Many have marked phobias by the ages o f three or f o u r as w e l l as u n c o n t r o l l a b l e temper o u t b u r s t s . In l a t e n c y , they may be e n e u r i t i c , e x p l o i t a t i v e o f pa r e n t s ' weaknesses, and show unusual c u r i o s i t y about the human body. Avoidance o f f r i e n d s h i p s , and u n s o c i a l and a g g r e s s i v e behaviour towards peers, i s common. The prognosis f o r t h i s f a m i l y ' s improvement i s guarded. G e n e r a l l y the d i a g n o s i s i s made too l a t e because parents are o f t e n r e f e r r e d f o r h e l p by a resource o u t s i d e the f a m i l y , and o n l y a f t e r the c h i l d has cr e a t e d s e r i o u s 150 problems f o r the community by h i s a n t i - s o c i a l behaviour. Parents i n t h i s group do not r e c o g n i z e the younger c h i l d ' s problems, because they are preoccupied w i t h the g r a t i f i -c a t i o n s t h e y can r e c e i v e from him. O u t - p a t i e n t treatment i s seldom e f f e c t i v e because o f the severe pathology i n the f a m i l y , and the parents' very l i m i t e d a b i l i t y to use h e l p c o n s t r u c t i v e l y . R e s i d e n t i a l treatment f o r the a c t i n g - o u t c h i l d may be i n d i c a t e d , or o u t - p a t i e n t treatment of the a d o l e s c e n t once parents have given up t h e i r r e s p o n s i b i l i t y f o r him. 4. The U n s o c i a l F a m i l y T h i s f a m i l y i s c h a r a c t e r i z e d by both p a r t n e r s ' l a c k of s o c i a l r a p p o r t w i t h other people and w i t h t h e i r s o c i a l environment. Prevalence of d e l i n q u e n t 'conduct and r e g r e s s i o n i n t o psychoses mark t h e i r s o c i a l a d a p t a t i o n . T h e i r c a p a c i t y f o r i n t e r p e r s o n a l r e l a t i o n s h i p s i s very l i m i t e d . P e r v a s i v e problems i n a l l areas o f s o c i a l f u n c t i o n -i n g are e v i d e n t . A) F i n a n c i a l F u n c t i o n i n g : Mental i l l n e s s and d e l i n q u e n t behaviour a d v e r s e l y i n f l u e n c e parents' a b i l i t y to provide f o r t h e i r f a m i l y . A poor work r e c o r d and i l l e g a l methods of o b t a i n i n g money c h a r a c t e r i z e t h e male p a r t n e r . Manage-ment of income i s poor and continuous r e c e i p t of s o c i a l a s s i s t a n c e i s common. 151 B. M a r i t a l R e l a t i o n s h i p : A number of female p a r t n e r s i n t h i s group have a h i s t o r y o f one or more d i v o r c e s . M a r i t a l d i s o r d e r s a s s o c i a t e d w i t h f i n a n c i a l and s o c i a l problems are p r e v a l e n t , and c r i s e s are p r e c i p i t a t e d by events which t h r e a t e n p h y s i c a l dependency s t a t u s , or s e x u a l adequacy o f a p a r t n e r . C. C h i l d - R e a r i n g : A t t i t u d e s towards c h i l d r e n are f r a n k l y r e j e c t i n g or e x p l o i t a t i v e . P h y s i c a l and emotional n e g l e c t charges a g a i n s t p a r e n t s , r e s u l t i n g i n s t a t e g u a r d i a n s h i p , occur w i t h frequency because of the c h i l d r e n ' s d e l i n q u e n t a c t i v i t y . D. C h i l d Development: The c h i l d r e n ' s c a p a c i t y f o r r e l a t i o n -ships i s extremely impaired, and a c t i n g - o u t behaviour i s p r e v a l e n t , such as delinquency, truancy and b i z a r r e conduct. The prognosis f o r the u n s o c i a l f a m i l y i s poor. L i t t l e i s known about treatment goals and methods to h e l p t h i s type of f a m i l y w i t h t h e i r severe problems. Miss V o i l a n d 1 suggests a more thorough understanding o f t h i s group's e t i o l o g y , needs and treatment methods i s r e q u i r e d because of the high cost of maladjustment t o these f a m i l i e s and to s o c i e t y . 1 V o i l a n d , A l i c e L. Family Casework D i a g n o s i s , Community Research A s s o c i a t e s Inc., New York, I960 . 152 f u r t h e r r e s e a r c h p r o j e c t i n t o f a m i l y d i a g n o s i s and treatment should be mentioned because o f i t s attempts to apply and t e s t a new framework w i t h i n which m a l f u n c t i o n i n g i n i n t e r p e r s o n a l r e l a t i o n s h i p s might be more c l e a r l y d e f i n e d , and t r e a t e d . The Midwest Seminar on Family D i a g n o s i s was e s t a b l i s h e d i n I 9 6 0 , and w i l l conclude i t s p r o j e c t i n 1 9 6 3 . ^ Delegates from s e v e r a l agencies are r e p r e s e n t e d i n the seminar. I t s g o a l i s to i n c r e a s e the caseworker's understanding of f a m i l y dynamics. To accomplish t h i s , each of the seminar members f o l l o w s a prepared guide i n the treatment of one or more cases and b r i n g s back the r e s u l t s to seminar meetings. T h i s has r e s u l t e d i n many r e v i s i o n s of the o u t l i n e and more are a n t i c i p a t e d . The guide suggests areas of f a m i l y f u n c t i o n i n g t h a t the caseworker needs t o be knowledgeable about, i n order to help them w i t h t h e i r problems. Understanding i s r e q u i r e d of the range of f a m i l y members' needs, the l o c a t i o n p f major needs, the power p o s i t i o n s of i n d i v i d u a l s t h a t may b l o c k the casework e f f o r t , the r e s o u r c e s of the members t h a t may be t u r n e d i n t o a s s e t s i n the h e l p i n g t a s k , and the r e l a t i o n s h i p s of the f a m i l y to other i n s t i t u t i o n s i n the 1 P o l l a k , 0., B r i e r l a n d , D. "The Midwest Seminar on Family D i a g n o s i s and Treatment", S o c i a l Casework, V o l . 42, J u l y , 1961. 153 community. An understanding o f the t o t a l f a m i l y group's ad a p t a t i o n i s c a l l e d f o r and i s obtained by s t u d y i n g the i n t e r a c t i o n i n th r e e sub-systems, the m a r i t a l r e l a t i o n s h i p , the p a r e n t - c h i l d r e l a t i o n s h i p and the s i b l i n g r e l a t i o n s h i p . Impaired r o l e performance i n one sub-system i s r e l a t e d t o performance i n the two o t h e r s . The two-way process i n s o c i a l behaviour i s kept i n mind. The i n f l u e n c e of i n d i -v i d u a l s o u t s i d e the group with whom f a m i l y members come i n contact i s i n c l u d e d f o r d i a g n o s t i c as w e l l as treatment purposes. Attempts are made to understand the f a m i l y ' s s u b - c u l t u r a l m i l i e u and t h e i r a t t i t u d e s about i t . The seminar attempts t o confi n e t h e i r study to the f o l l o w i n g p o i n t s : 1. What i s the most burdensome problem? 2. Is the problem a f f e c t e d by a d e f i c i t or excess i n f a m i l y membership? 3. I s the problem c r e a t e d by the i n t e r a c t i o n m u t u a l l y harmful? 4. Does the problem result-".frpm e x t e r n a l p r e s s u r e s , such as long-term h o s p i t a l i z a t i o n or unemployment, or monetary demands t h a t cannot be met by the f a m i l y income? 5. Is the problem c r e a t e d by the i n t e r n a l pressures of one p a r t n e r , which would i n t e r f e r e w i t h h i s c a p a c i t y f o r s a t i s f a c t o r y r e l a t i o n -s h i p s , r e g a r d l e s s o f the c h a r a c t e r i s t i c s o f the other p a r t n e r ? 6. In view of the ca u s a t i v e f a c t o r s , how can the caseworker h e l p the members of t h i s f a m i l y group change? Some study has been gi v e n to the s e l e c t i o n o f 154 a p p r o p r i a t e cases to t e s t the f a m i l y focus d e s c r i b e d above. F a m i l i e s whose d y s f u n c t i o n i n g was so g r e a t t h a t l i t t l e pro-gress could be expected were excluded; g e n e r a l l y long-term cases were s e l e c t e d although some i n t e r e s t was expressed i n t e s t i n g t h i s method wi t h s h o r t - t e r m cases. Some f o s t e r and adoption homes were i n c l u d e d because of the t o t a l f a m i l y involvement i n placement cases. Three major casework methods are being used" j o i n t and f a m i l y i n t e r v i e w s , home v i s i t s , and p a r t a k i n g o f a meal i n the home. Although j o i n t and f a m i l y i n t e r v i e w s are g i v e n pre-eminence, i n d i v i d u a l i n t e r v i e w s are a l s o arranged, a c c o r d i n g t o the f a m i l y member's requirements. In order t o s e t a p p r o p r i a t e treatment g o a l s , r e c o g n i t i o n i s given t o the developmental stage of the f a m i l y group. For example, newlyweds may need h e l p i n emancipating themselves from t h e i r parents, and i n s t r e n g t h -ening the m a r i t a l r e l a t i o n s h i p ; parents may need t o modify t h e i r attachments to each other because of t h e i r c h i l d r e n ' s needs; when c h i l d r e n enter s c h o o l , parents may need a s s i s t a n c e i n h e l p i n g them s e p a r a t e . C l a r i f i c a t i o n o f the w o r k e r - c l i e n t r o l e i s r e c o g n i z e d as e s s e n t i a l i n e s t a b l i s h i n g c o l l a b o r a t i v e e f f o r t s to achieve the treatment g o a l s , as w e l l as a casework focus on immediate and on long-term o b j e c t i v e s . 155 Drs. Otto P o l l a k and Donald B r i e r l a n d r e p o r t t h a t the p r o j e c t thus f a r has i n c r e a s e d the understanding o f seminar members i n t h e d i a g n o s i s and treatment of family-problems . I t may be seen from these s t u d i e s t h a t s o c i a l casework i s becoming i n c r e a s i n g l y i n t e r e s t e d i n d e v e l o p i n g and t e s t i n g hypotheses r e l e v a n t to a f a m i l y focus i n case-work. These r e s e a r c h p r o j e c t s have sharpened up d i a g n o s t i c elements i n f a m i l y casework, and have endeavoured to s y s t e -matize the r e c o r d i n g so t h a t p e r t i n e n t f a c t s about f a m i l y f u n c t i o n i n g are obtained and used i n the treatment p r o c e s s . Other p r o f e s s i o n s , such as s o c i o l o g y , anthropology and medicine, have c o n t r i b u t e d v a l u a b l e knowledge of i n d i v i d u a l and group behaviour which i s b e i n g u t i l i z e d and adapted by the s o c i a l work p r o f e s s i o n . To date, s o c i a l agencies have been more a c t i v e than p s y c h i a t r i c c l i n i c s i n d e v e l o p i n g f a m i l y casework; c l i n i c a l s e t t i n g s , which have a l a r g e estab-lishment o f s o c i a l caseworkers, c o u l d u t i l i z e the f i n d i n g s from these s t u d i e s as a b a s i s f o r f u r t h e r r e s e a r c h i n t o f a m i l y casework. F i n d i n g s from the Sample Case Records Judging from many o f the recorded assessments, the casework focus i n the d i a g n o s t i c p e r i o d i s o r i e n t e d t o i n d i v i d u a l f a m i l y member's emotional problems. How these 156 d i f f i c u l t i e s may be i n f l u e n c i n g the c h i l d i s not d e s c r i b e d . I t i s understood t h a t the c h i l d ' s psychopathology i s the r e s u l t o f unhealthy p a r e n t - c h i l d r e l a t i o n s h i p s , but no con-j e c t u r e s are made on the purpose h i s a d a p t a t i o n f u l f i l l s f o r the f a m i l y group. Pew casework e v a l u a t i o n s are r e c o r d e d on the p a r e n t s ' f u n c t i o n i n g i n the important r o l e s they are c a l l e d upon t o p l a y . T h e i r s u b j e c t i v e responses to the behaviour of the r e f e r r e d c h i l d are g e n e r a l l y d e s c r i b e d , but casework e v a l u a t i o n s of t h e i r a t t i t u d e s towards him are i n -f r e q u e n t l y made. With many parents, i t i s very d i f f i c u l t to estimate how much acceptance or r e j e c t i o n they do f e e l f o r the c h i l d , but i t should be p o s s i b l e i n more cases to make a t e n t a t i v e assessment, and t o e v a l u a t e parents' m o t i v a t i o n i n m o d i f y ing negative a t t i t u d e s which are c o n t r i b u t i n g to h i s d i s t u r b a n c e . The connection between impaired m a r i t a l and d i s t u r b e d p a r e n t - c h i l d r e l a t i o n s h i p s are not r e c o r d e d . D e s c r i p t i o n s o f f a t h e r - c h i l d r e l a t i o n s h i p s are l a c k i n g , as w e l l as i n f o r m a t i o n on s i b l i n g s . The f a m i l y ' s f u n c t i o n i n g was not assessed as to the h e a l t h andppathology w i t h i n the group. One way of determining major p a t t e r n s of f a m i l y r e l a t i o n s h i p s i s through e x p l o r a t i o n of t h e i r r e l a t i o n s h i p s w i t h t h e i r immediate community. Caseworkers co u l d focus more on t h i s aspect of the f a m i l y ' s a d a p t a t i o n i n i n t e r -views, p a r t i c u l a r l y home v i s i t s , and t hrough more d i r e c t s c h o o l contact when l e a r n i n g d i f f i c u l t i e s are one of the c h i l d ' s symptoms. 157 More e x p l i c i t r e c o r d i n g on i n t e r n a l and e x t e r n a l f a m i l y r e l a t i o n s h i p s might c o n t r i b u t e t o the team a f u l l e r u nderstanding o f the c h i l d ' s and pa r e n t s ' problems, and might l e a d to a more comprehensive assessment of the a c t u a l and p o t e n t i a l r e s o u r c e s t h a t are a v a i l a b l e f o r h e l p i n g the f a m i l y achieve a more s a t i s f a c t o r y adjustment. I t would appear, from the f o r e g o i n g comments, t h a t s o c i a l casework i n the d i a g n o s t i c phase i n the C h i l d -ren's C l i n i c emphasizes the " c l i e n t and h i s f a m i l y . " "*" By c o n t r a s t , Dr. Sherman suggests t h a t f a m i l y a n a l y s i s 2 o r i e n t e d t o the " c l i e n t i n h i s f a m i l y ^ i s more i n keeping w i t h the s o c i a l work t r a d i t i o n and w i t h the needs o f the C l i n i c a l s i t u a t i o n . With the " h o l i s t i c " approach, attempts are made to understand the whole f a m i l y as a c o n d i t i o n of comprehending the i n d i v i d u a l ; by c o n t r a s t an " a t o m i s t i c " o r i e n t a t i o n endeavours to comprehend the whole ( f a m i l y ) by i n t e r r e l a t i o n and s y n t h e s i s o f i t s i n d i v i d u a l members. Dr. Sherman b e l i e v e s t h a t t h i s l a t t e r approach p l a c e s undue emphasis on the problems o f the r e f e r r e d f a m i l y member, r a t h e r than v i e w i n g the i n d i v i d u a l ' s d i f f i c u l t i e s as a symptom of pathology i n the whole group. T h i s i s a p a r t i c -u l a r l y r e l e v a n t d i s t i n c t i o n t o bear i n mind i n the treatment 1 Sherman, S.N. "The Concept o f the Family i n Casework Theory", E x p l o r i n g the Base f o r F a m i l y Therapy, F.3.A.A., New York, 1961, p. 18. 2 Loc. c i t . 158 of disturbed children, f o r the burden of the problems must be shared by the family before the c h i l d can be helped towards a healthier adaptation. That a h o l i s t i c focus, i s , at times, established and maintained i s apparent from some of the sample cases i n the treatment period. I t i s d i f f i c u l t to determine why these cases do not r e f l e c t t h i s approach i n the diagnostic stage. Lack of time may be a fac t o r , and a hi s t o r y of the child ' s and parents* problems may take p r i o r i t y ; or the family's current functioning may be communicated ver b a l l y i n conference. Whatever the causes, i t would seem advisable to record such information wherever possible, to f a c i l i t a t e c l i n i c a l and psychosocial ".diagnoses, and to compare changes i n family functioning during and at the end of treatment with the o r i g i n a l assessment. Helen Perlman writes "Our diagnostic concern i s to under-stand those factors that cause or are  associated with the ( c l i e n t ' s ) d i f f i -culty and those that may be mobilized  to cope with i t . This w i l l require our closer study and understanding of the dynamics of s o c i a l i n t e r a c t i o n and of the psychology of the s o c i a l . " 1 Recording i s needed not just f o r i t s own sake, but because i t w i l l f a c i l i t a t e the formulation of treatment goals. As Mrs. Perlman puts i t , concentration upon p a r t i c u l a r r o l e s 1 Perlman, H.H. "The Role Concept and S o c i a l Casework: Some Explorations," S o c i a l Service Review. Vol. 35, No. 4» Univ. of Chicago Press, Chicago, 111., p. 380 (underlining added). 159 in which the individual i s experiencing trouble " w i l l give boundary, focus and direction to the caseworker's a c t i v i t y . " ^ It i s therefore recommended that discussion of the C l i n i c ' s and the parents' treatment goals be recorded; this can help in the establishment of a focus for parents and caseworkers on the problem-to-be-worked, and w i l l provide a guide for the caseworker, parents, and team to evaluate a family's needs in relat ion to the C l i n i c ' s treatment re-sources. Such recording would also have a bearing on the decision to terminate, and would enable the caseworker and parents to determine more clearly when the treatment goals have been achieved. Role confusion on the part of the soc ia l worker is apparent in the recording of some of the sample cases. It i s l i ke ly that this confusion makes i t d i f f i cu l t for caseworkers to assess when families have been suff ic iently helped by them to work towards termination. However, i f the task of the caseworker is understood as helping "the person in interaction 2 with some problematic aspect of his social rea l i ty " 1 Perlman, Social Service Review, p. 376. 2 I b i d . , p. 372. 160 then termination should be considered when the c l ient T s ab i l i ty to carry his previously impaired social roles and his l i f e tasks have been restored or improved. The selected f i l e s analyzed in the present study are a reasonable sample of the Children's C l in ic direct treatment cases in regard to duration of each family's contact with the C l i n i c , which i s approximately one and a half years. 1 It is wondered i f the treatment time on some cases might be curtailed i f the social worker's role in this setting were c l a r i f i ed . This is an important question in view of the restricted intake at the time this study was being made. Some thought and practice might be given to the establishment of c r i t e r i a for long and short term treatment. Dr. Caplan hypothesizes that neven a very small influence exerted by a significant person during (family) c r i s i s may be enough to decide the outcome either in the direction of 2 mental health or of mental i l l - h e a l t h . " He is referring to those families who are basical ly healthy but in which a cr i s i s situation precipitates a break-through of family pathology. The results of this study suggest that social workers might be more secure in the ir area of competence, 1 This includes the to ta l time a family has been in contact with the Cl inic • 2 Caplan, Gerald, Prevention of Mental Disorders in Children. Basic Books Inc. , 1961, p. 310. 161 which has been defined as helping the c l ient enhance his social functioning. In the closed cases, the recording indicates that more improvement in the chi ld ' s and parents" adaptation was achieved where this focus was established and maintained. The cases in which the socia l worker concen-trated on the c l ient ' s intra-psychic conflicts without re la t-ing these to inter-personal d i f f i cu l t ie s and to role perfor-mance, both within and outside the family, showed the least improvement. On the basis of the above findings, i t can be concluded that the caseworker needs to know how the c l ient ' s personality dynamics are expressed in his current social relationships and tasks, part icularly in the areas where he i s experiencing problems, in order to help him achieve a better adaptation to his l i f e circumstances. People's closest relationships take place within the family group, and i t is here that basic attitudes towards the s e l f and others are experienced, formed and expressed. The family unit provides a firm or an unsound foundation for i t s members' relationships and act iv i t ie s that take place out-side the group. What happens within the family may influence every sphere of the individual 's l i f e outside i t . While external circumstances can and do have their impact on the primary group, Western culture recognizes the family as the foundation of society, and as the main influence in shaping 162 human beings. This part icularly true of the ch i ld . I f the view is accepted that a chi ld ' s disturbance is an expression of pathology in the family unit , then the way in which the unit functions is the appropriate treatment focus in Child Guidance C l in i c s . Much remains to be done to establish role theory, and to integrate psychological theory with i t . However, these concepts together seek to understand family re lat ion-ships and the social functioning;of individuals , in the context of their group and of society. Mrs. Perlman states that family diagnosis today " i s an effort - not yet achieved for the most part - to assess a configuration of forces, patterned not simply by the personalities involved but also  by their roles in relat ion to one another." 1 She outlines four aspects of the c l ient ' s socia l behaviour that are of primary import to the caseworker. F i r s t , there are socia l act iv i t ies and tasks involved in the role(s) in which the cl ient is experiencing trouble. What act iv i t ies does he carry out, and how does he do them? Secondly, the cl ient carries these act iv i t ie s in soc ia l interaction with others, 1 Perlman, Social Service Review, p. 376. 163 who w i l l be involved in causing or affecting his problem, in i t s solution and consequences. These others need to be considered both in diagnosis and treatment of the c l ient ' s problem, and the individual must be viewed not as an entity alone, but as a person involved in an interaction process. Thirdly, between the cl ient and other people, there are psychologically significant and socially-determined norms and expectations as to the way he and the others per-form their tasks. The caseworker needs to learn from him what his ideas of the role norms are, as well as what he has invested in them emotionally, and to compare those con-ceptions with the range of the community's standards. How a person behaves in a situation is not determined alone by unconscious drives and needs, but is also influenced by his conceptions of the way in which he and others perform their tasks, and what he expects to give and to receive. F ina l ly , personal attitudes and v i t a l feelings are invested in these socia l tasks, in the role interaction, and in the c l ient ' s expectation of the outcome of reciprocal roles . Value judgments of two major sorts are l ike ly to be made here: a) those that are generally agreed upon by the culture at large and b) those that each individual invests in certain roles . The caseworker is concerned primarily with 164 this la t ter aspect of feelings. " A l l or any aspects of personality may be involved in the performance of v i t a l roles . So the role concept carries the constant reminder that feelings, attitudes, personality i t s e l f , are the product-in-process of old and current experiences of soc ia l ly required behaviour (roles), and socia l ly provided rewards and frustrations (role valuations)," 1 Recommended Changes in the Social History Structure The importance of the principle that the person-a l i t y of the c l ient i s a product-in-process of old and current experiences is i l lus trated by this present study's evaluations of treatment. The cases where th i s principle was kept in mind showed the most improvement in both the chi ld 's and the parents' adaptation. This focus should be established in the diagnostic period. One method of f a c i l i -tating this is to consider revision of the standard socia l history format. The term " soc ia l history" i t s e l f might be replaced by another phrase, such as "psychosocial diagnosis of the family" to ref lect current socia l work theory. In the introduction to the socia l history outline now in use, (seeAppendix C) four broad areas of interest "basic to a psychiatric diagnosis" are outlined: "the 1 Perlman, Social Service Review, p. 3#0. 165 problem, family background, personal history, and the 1 referror's evaluation and plan". The term "family background" does not take into account family functioning, except the parents' feelings about and relationship to other family members, and how the child uses outstanding relationships. In one sentence in the outline, the chi ld ' s feelings and needs are related to his behaviour in his closest relationships, but which concepts might be used to analyze such a complex process are not mentioned. This outline was devised several years ago. It cannot, therefore, reflect the current focus of social casework, and the attempts that are being made to integrate the psychological and social components of the c l ient ' s problem. The family is not viewed as a whole, but rather as a col lect ion of separate individuals - mother, father, and child - and information requested on siblings is sparse. It is apparent that a change in focus from the individual to the individual in his family is called for, and vague descriptions of relationships replaced by more definite concepts. Role theory can contribute towards a more expl ic i t framework within which to describe family relationships. Regarding personal history, knowledge of the chi ld ' s 1 Quoted from the social history outl ine. 166 background would seem to be part icularly useful in under-standing his particular problems, but i t is thought that the time spent in gathering information on the parents1 separate backgrounds could be more profitably used in learn-ing about their adaptation since their marriage. I f more c lar i f ica t ion is needed on personality aspects of parents' functioning, individual histories could then be discussed. The policy of obtaining background information on the parents might make some of them more defensive than necessary about receiving help, and places a responsibi l i ty on the caseworker to gather information which may not always be pertinent to the immediate problems the family is concerned about. The h i s tor i ca l concentration on parents' backgrounds may contribute to the role confusion of the caseworker and therefore of the parents as c l ients , for they may become patients before they are rea l ly engaged as c l ients . Such a situation might create a barrier between the parents and the worker in their co-operative efforts to help the disturbed chi ld . The following revisions are recommended: The Problem 1. A statement of the problem from the parents' viewpoint, the changes they hope for, and a casework assessment of their expectations and motivation. 2. Description of family's current functioning in the following areas: a) economic b) marital c) chi ld rearing d) with the community. Specific areas of d i f f i cu l ty should be identi f ied. Description of role performance of parents in problem areas. What ac t iv i t ie s do they 167 carry out, and how do they do them? How is each person affected in his role performance by the other(s)? What does each parent expect from himself, his spouse and child(ren)? Are these ex-pectations within "normal" l imits in terms of his social mil ieu, age and personality? What personal attitudes and feelings are invested in these socia l tasks, in the role interaction, and in the c l ient ' s expectation of the outcome of reciprocal roles? What is  the ma.jor source of stress to the  parents? What are the areas of strength in the family's functioning? Can any ascendant pattern of family re lat ion-ships be identified? History of family's functioning: s igni-ficant events in the family's l i f e , such as advent of children, which would throw more l ight on family's current functioning. 3. Individual Factors a) Assessment of parents' ego strengths b) Pertinent h i s tor ica l information which could contribute to an understanding of problem areas in parents' functioning. 4. Casework Evaluation: Assessment of the core problem in family functioning to which the referred child is reacting; resources within the family and commun-i t y which might be mobilized to help the chi ld . The revisions which have been suggested require the test of time and practice before their usefulness can be determined. The most basic requirement, however, is a change in casework focus in the diagnostic period, from emphasis on each individual ' s emotional adjustment, to an understanding and recognition of the relationship between 168 these inner d i f f i cu l t i e s and inter-relationship problems within the family. And i t i s only on the basis of much research and experience that social casework w i l l be able to define family diagnosis with any degree of certainty, for at this point, i t is only in the stage of tentative formulation. It should be added that certain families may take much longer than others to disclose to the caseworker those features in their inter-action with each other which are contributing to the chi ld ' s d i f f i cu l t i e s . Timing is an impor-tant element in fact-finding. Any outline should be used with sensi t iv i ty for the c l i ent ' s readiness to discuss those aspects of family relationships that are charged with fear, anger and gui l t for them. It w i l l not be possible, with some families, to have a l l the information relevant to a psychosocial diagnosis by the end of the formal assessment period. This should not be cause for concern, because con-tinuous diagnosis i s an integral part of the treatment process unt i l termination. Team conferences can be arranged at the worker's discretion i f facts which might alter the course of treatment are disclosed following the diagnostic period. Another method to describe and measure family functioning is elaborated in the Varwig 1 McCallum 2 1 Varwig, R., Family Contributions in Pre-School Treatment  of the Hearing-Handicapped Child, M.S.W. Thesis, U . B . C , I960. 2 McCallum, M . F . , Family Differentials in the Habil i tat ion  of Children with Brain In.iurv. M.S.W. Thesis, U . B . C , 1961. 169 theses. These studies organized the recorded data on the chi ld ' s and parents* functioning under three headings according to the extent of impairment. This led to the establishment of a rating scale; the chi ld ' s and parents* adaptation were measured between two points in time. This kind of measurement would be possible in the Children's C l in ic i f the f i l e s contained more specif ic information on the family's functioning at the end of the diagnostic period and at specified times thereafter. Methods of Treatment Another important conclusion related to treatment method. The term "family-focus*1 is not meant to imply that a l l family members be included in treatment, or that family-unit cases and interviews should be structured in most cases. Shared cases and individual interviews may frequently be the appropriate treatment method, but the c l ient ' s feelings, attitudes and behaviour should be related, ultimately, to current family functioning. More definite concepts should be developed regarding unit and shared cases, and individual , joint and family interviews. The key participants in the particular problems for which the family i s requesting help should be involved in treatment, and other family members should be included as the caseworker i s alerted to the advisabil i ty of this in order to relate the family balance 170 to treatment goals. Dr. Ackerman says: tt0f necessity, the proper sequence of diagnostic and therapeutic interviews involving individuals, family pairs or the entire family group varies from family to family. In the case of a chi ld patient the interviews may, for example, take the following order: an interview with the chi ld and mother together, an interview with the child alone, an interview with chi ld and father, and, f i n a l l y , an interview with the two parents without the c h i l d . It might also enta i l at an appropriate point an interview with the chi ld and both parents, or the chi ld and s ib l ing together with one or both parents." 1 Regarding the inclusion of s ibl ings , i t deserves exploration whether the earl ier involvement of the chi ld who represents the "good" aspect of parents' personalities compared to the referred chi ld ' s "badness", would expedite diagnosis of the chi ld ' s problem and shorten the treatment period. This would be an interesting subject for experi-mentation in the Children's C l i n i c . Recording Policy and Methods This topic i s not directly related to family diagnosis and treatment, but i t is an important adminis-trative aspect of casework. It also has some bearing on treatment when the social worker shares cases and is part of an inter-discipl inary team. Furthermore, improved recording leads to better measurements of casework s k i l l s . 1 Ackerman, The Psvchodynamics of Family L i f e , p. 306. 171 Recording has long been the bane of the case-worker's occupation; this i s possibly due to the elusive nature of the transactions which take place between client and worker. The records studied as a sample are highly individualized; some are lengthy and describe in deta i l the c l ient ' s behaviour only; others are pertinent and concise and depict the interaction that took place during interviews; many do not contain an assessment of the c l ient ' s needs, goals and use of treatment, but seem to meander, without direction, from interview to interview. On many of the closed cases, no attempt was made to compare the c l ient ' s social adaptation at the beginning and at the end of treat-ment. Some of the active cases contained no entries for the past several months. The policy of holding progress conferences at least every s ix months was not adhered to in many of the cases according to the records. It is questioned whether the recording studied accurately reflects the transactions which took place be-tween c l ients , caseworkers and teams. Two of the active cases that do not appear to have achieved any treatment goals have, in actuality, made excellent progress despite 1 poor prognoses. It is beyond the scope of this study to evaluate the accuracy of the recording, but certain recom-mendations can be made about i t . 1 This information was obtained from one of the psychiatrists . 172 Accurate, concise recording is important for a number of reason: 1. i t can help the caseworker think through the mass of material that is presented, and thus enable her to focus on the core problem; 2. i t may help to focus team discussion in diagnostic and progress con-ferences; 3. i t may fac i l i t a te communication between workers on shared cases; /*• i t can expedite the re-opening and transfer of cases; 5» i t would greatly assist research projects, for many studies are conducted from the records in this setting; 6. office management of records would be fac i l i t a ted . Because of the apparent lack of recording con-ventions in this setting, i t is thought that caseworkers would welcome a more definite policy. It has been the experience of other agencies that the establishment of re-cording conventions must be accompanied by caseworkers' continuing interest in using, testing and recommending revisions of these pol ic ies . Conclusions on the Effectiveness of Family Casework The formulation of definite conclusions from this study is l imited by the small number of sample cases, and by the arbitrary nature of the decisions which were made on many of the items in the schedules, part icularly in schedule B. An additional impediment to this research 173 project i s that the recording i s treatment-oriented and the f i l e s are not organized for research purposes. Further-more, casework is a highly individualized, creative art , and even the most expl ic i t recording may be unable to cap-ture the essence of the interaction which takes place between the cl ient and the worker. These limitations must be kept in mind in consider-ing the results of this study. Some tentative conclusions can, however, be made. It would appear that some casework which is practiced in the Children's C l in ic is family-centred, while some is oriented towards the individual ' s inner conflicts without relat ing these problems to his social adaptation. In these latter cases, i t would seem that another important connection is not made, that of re lat ing the c l ient ' s prob-lems to the treatment goals. A third group of cases emerges; those where the recording is too sparse to evaluate the focus and outcome of treatment. Of the sample cases, those which were family-centred recorded the greatest amount of improvement in the c l ient ' s functioning. These f i l e s reflected more certainty of purpose on the caseworker's part than was evident in the single client problem-centred cases. The caseworker's 174 professional maturity may have considerable influence on the security with which she can establish, maintain and record the treatment focus and process. Other factors are involved, however, such as educational influences, and administrative expectations and assistance. The casework focus in any organization w i l l l ike ly depend, to some extent, on the s taf f ' s educational backgrounds, and on the particular orientation of i t s adminstration. It may be expected that casework w i l l be influenced more by tradit ional psychiatric approaches in a psychiatric c l i n i c than in other settings. However, each discipline in a c l i n i c a l team needs to know the extent and boundaries of i t s professional responsibi l i t ies in order to u t i l i z e i t s maximum potential . A more definite concept of the social caseworker's role in this setting is desirable. Steps are now being taken in this direct ion. Attempts are currently being made to adapt the social role therory/ to casework practice in the Children's C l i n i c ; some consultation is available from the University of B r i t i s h Columbia's School of Social Work in this regard. Staff meetings, u t i l i z i n g the Hawley study 1 Hawley, C M . , Role. Stress and Social Casework Practice. Master of Social Work Thesis, University of Br i t i sh Columbia, 1961. 175 on role theory which was conducted in 1 9 6 1 , have been held. A growing interest in family diagnosis and treatment is evident. Some caseworkers are beginning to experiment with family group interviewing methods. Administration is giving scope and encouragement for such experimentation to take place, with the emphasis on the creative adaptation to casework, of new theories and techniques. More home v i s i t s and community contacts might also be encouraged. This study indicates that these steps are desirable and necessary i f social casework is to adapt new knowledge to what may be a more rewarding practice, both for the case-worker and the cl ient who seeks his help. Another resource, however, beyond the scope of the C l in i c ' s existing f a c i l i t i e s , i s required to improve i t s services. This is the establishment of a research position. Provision of more direct treatment personnel and in-service training programs are also required. But even more essential i s a sc ient i f ic evaluation of the existing program. The needs of disturbed families that the Cl in ic meets should be identi f ied, as well as those that are not met. More knowledge is required on the reasons for improve-ment, or lack of i t , in the families treated. Sucn infor-176 mation could lead to the establishment of t reatabi l i ty c r i t e r i a . Of utmost importance to caseworkers in Child Guidance Cl inics i s the identif icat ion of methods to help parents improve their relationships with their disturbed chi ld . This thesis has i l lus trated that concentration on the parents' emotional conflicts does not automatically result in better family functioning, nor in improvement in the chi ld 's adaptation. Family-centred casework, in which the overt and subtle inter-actions between family members are studied, identi f ied, and treated, is l i k e l y a more effective casework method to help families with disturbed children. This in i t s e l f i s a broad f i e l d for the trained researcher. Classi f ication of family disorders and ident i-f ication of appropriate treatment methods need further development; new concepts, such as role theory, require testing for their usefulness to family-centred casework, and more study is required to integrate sociological and psychological theories. Dr. Ackerman states that the re-searcher and the c l in ic ian must join forces to accomplish these ambitious goals. It follows that standardization of case records is required as a preliminary step in research into family diagnosis and treatment. 1 7 7 Appendix A Schedule A. Suggested Criter ia for Evaluation of  Emotional and Social Adjustment Cr i ter ia Explanation of Ratings A .FGood B. Fair C. Poor 1. Symptoms of Emotional Disturbance Predominantly neur- Mixed sympto- Predominantly otic symptoms, such matology of behaviour dis-as phobias, fears, A and C. order symptoms eneurises, t i c s , such as exees-accompanied by sive aggression, excessive gu i l t , ly ing , stealing, truancy, with-out excessive gu i l t . 2 . Physical Develop-ment Within normal Fa i r ly healthy Slow physical l imi t s ; no ser i - chi ld , but suf- development due ous i l lnesses . fers periodi- to several i n -cal ly from cidents of physical i l l - severe i l lnes s -ness and/or es in past, one serious i l lness in the past. 3 . Function-ing Level of In te l l -igence Superior Average Dull Normal Intelligence. Intelligence. Intelligence. 4. Learning Capacity Alert and quick Slow or incon- D u l l , unrespon-in understanding; sistent in sive; highly eager to learn, understanding di s tract ib le ; explore; good and/or in re- lacks motivation attention span sponding to in learning. learning situation. 178 Schedule A. continued Cr i ter ia Explanation of Ratings A. Good B. Fair C. Poor 5. Response to  New Experi-ences Adjusts well to new Reacts to new ex-experience or change in routine or program. periences by: some withdrawal; overt h o s t i l i t y ; some disorgani-zation of behav-iour; lack of confidence in se l f . Marked with-drawal or dis-organization when faced with new ex-peri ences• 6. Ab i l i ty to Relate Interested in re-lationships with others; is active-l y reaching out for relationships; shows sensi t ivi ty to others' fee l-ings • Child relates superf ic ia l ly with minimal self- involve-ment or positive expectation; some question around the chi ld ' s wish for relat ion-ships. Child clearly indicates un-willingness to invest sel f in re-l a t i o n s h i p s © 7. Emotional  Develop-ment Independence and self-assurance appropriate to chi ld ' s age. Demanding and attention see shy and self-scious; needs reassurance, ort and l imit i s appropriat age. Excessively king; dependent, con- clinging and more demanding; supp- needs con-s than stant support e for and approval or denial of dependancy needs. 179 Schedule A. continued Cri ter ia Explanation of Ratings A. Good B. Fa ir C. Poor 8. Self-Control Able to postpone immediate grat i-f ication approp-riate to age; able to accept reason-able l imit s . Sullen, crying or mild temper tan-trums when reason-able l imits set; inconsistent re-actions to own impulses; stub-bornness. Typical response to own impulses or l imits i s angry, destruc-tive behaviour or r i g i d self-control. • Concept of Self Self-awareness appropriate to chi ld ' s age; com-fortable accep-tance of se l f ; strong sense of identity. Child has some self-awareness but evades or does not accept undesirable fee l-ings and behaviour, behaviour onto others; lacks conscience. Child has l i t t l e awareness or concept of se l f ; projects respon-s i b i l i t y for 10. Relation-ship with  Mother Warm and relaxed; responds to love and affection. ambivalent; Openly negati-loving and hating; v i s t i c and overly compliant resentful or or defiant. withdrawn with lack of communi-cation and affection. 11. Relation-ship with Father As above. As above. As above. 180 Schedule A. continued Cri ter ia Explanation of Ratings A. Good B. Fair C. Poor 12. Relation-ship with  Siblings Appropriate and mutual acceptance and affection. Obvious ambiva- Extreme r iva l ry lence expressed and jealousy; by over solicitude extremely over-towards s ibl ings , l y sol ic i tous , or frequent re-sentment. 13• Relation-ship with  other chi ld  ren in the  Community Friendly, co-op- Shy - slow in erative; able to making friends; accept others' quarrelsome; re-leadership or is lates only to accepted as leader, younger children or small group of children; domin-eering or easily dominated. Predominantly hostile and aggressive or fearful , with-drawn - seldom plays wit h other children. 14. School Adjustment Appropriate academic and social perform-ance and adjust-ment. Academic perform-ance and/or social adjustment below par as shown by inab i l i ty to con-centrate on school work and/or inter-mittent social d i f f i cu l t ie s with class mates. Reported fre-quently by school as having chronic academic1 or social dif f i- ; culties or chile actively rebel-l ing or with-drawing from school. 15. Child's viem of his role  in family Child feels loved and accepted by parents and s ibs ; is an active participant in family l i f e ; has strong sense of belonging. Child has some q question of fam-i l y ' s acceptance of him but is able to participate to a moderate degree in family l i f e with some sense of belonging. Child frequently feels excluded from the family group, feels lonely and scape-goated; is an isolated member. 181 Schedule A. continued Cri ter ia Explanation of Ratings A. Good B. Fair C. Poor 16. Relation-ship to  Adults (Clinic Staff) Relates wel l , fr iendly. Shy and inhibited or attention-seeking and errat ic . Negativist ic ; withdrawn; distrustful and fearful . 17. Range of  Emotional  Disturbance in Child Child behaving essentially within normal l imi t s ; mild symptoms which don't impair functioning to a pathological degree in any area e Specific areas of maladjust, i . e . family or peer relationships or achievement im-paired while some areas free 06fidisturbance„ Child finds l i t t l e satis-faction in either relat ion-ships or achieve ment areas; social function-ing generally markedly im-paired. 18. Treatment  Recommend-ations No treatment of child or family required. Child requires direct out-patient treat-ment and/or modification of environment. Child re-quires inten-sive in-patient treatment. 182 Appendix B. Schedule B. Suggested Cr i ter ia for Assessment of the Family Cri ter ia Explanation of Ratings A. Good B. Fair C. Poor 1. Family's Income Steady income, ade- Occasional or Living on marg-quate to maintain threatened loss inal income; family's standard of income, caus- in receipt of of l i v i n g . ing actual or Social Assis-anticipated prob- tance or Unem-lems in l i v i n g ployment In-standards. surance, with resultant sub-standard l i v i n g conditions. 2. Employment Father has good Father employed, Father unem-work record; perma- but unemployment ployed; season-nent employment subject to change a l employment with job satis- depending on soc- only; poor factions, i a l conditions or work history, relationship d i f f i -culties with em-ployer. 3. Housing Comfortable, Adequate from hy- Crowded and spacious home. gienic, but not unhygienic from aesthetic l i v ing standards; does quarters. not allow for sufficient space for parents or children. 4. Training of Fathers for Employment Professional or Par t i a l ly trained No specific vocational t ra in- for professional training or ing, adequate to or industrial po- developed s k i l l s qualify for and s i t i on , with possi- to qualify for maintain position, b i l i t y of completing specific t ra ining. posit ion. 183 Schedule B. continued Cr i ter ia Explanation of Ratings A. Good B. Fair C. Poor 5* Socio-Economic Status High standard of l i v i n g , recognized social position. Middle-class Low status occu-status around pation, income, occupation and and l i v i n g con-l iv ing conditions, di t ions , with limited possi-b i l i t y for advan cement• 6 . Marital  Relation-ship Harmonious, happy marriage, mutual affection and re-spect, sharing of interests, goals and responsibil-i t i e s . A b i l i t y to maintain communi-cation for resol-ution of confl icts . Some evidence of marital conf l ict , not openly recog-nized and resolv-ed. Pursuit of similar goals and sharing of respon-s i b i l i t i e s l imited. Gross disharmony between spouses; serious lack of communication, support and understanding; disruption of marriage a poss ib i l i ty . 7. Financial  Management Both partners plan and manage wisely within a reasonable budget, without ex-cessive concern about f inancial s ituation. Conflict between partners over man-agement of finances despite adequate finances; inconsis-tent or r i g i d hand-l i n g of money; i n -debtedness. Heavy debts; chaotic house-, hold manage-ment ; couple unable to plan together re f inancial management. 8. Mother- Child  Relation-ship Basically sound, warm and close; chi ld receives s t ab i l i ty and security; is lov-ed and wanted. Baffled by ch i ld ; ambivalent fee l -ings towards ch i ld ; inconsistent hand-l i n g ; some projec-tion of family problems onto child. Marked lack of warmth and understanding; severe rejec-tion of the chi ld , or smothering over-solicitud< 9. Father-Child  Relation-ship As above. As above. As above. 184 Schedule B. continued Cr i ter ia Explanation of Ratings A. Good B. Fa ir C. Poor 10. Relation,  ships  Amongst  Siblings Positive emotional t ies and mutual identi f icat ion; conflict within normal l imits for ages of children. Emotional t ies weak; frequent fighting in forms of physical or emotional cruelty; reaction formation suspected. Emotional t ies among children lacking; con-f l i c t between them warrants frequent inter-vention. 11. Family  Solidar-i t y Evidence of co-hesiveness and strong sense of family identity; members pul l to-gether in times of stress; con-f l i c t within fam-i l y dealt with quickly and appro-r i a t e ly . Ambivalent emo-tional t ies be-tween family mem-bers and l i t t l e sense of family identity, or too much "togethernes conflicts are i n -appropriately dealt with. Marked lack of cohesiveness and emotional t ies amongst family; no sense of family iden-s"; t i t y ; conflict persistent and severe. 12. Parents' View of  the Child's  Role in the  Family Parents accept chi ld as part of the family group, and make efforts where necessary to support his place in the family. Parents are ambi-valent about the chi ld ' s r ightful place in the fam-i l y group; over-protectiveness or lack of ade-quate support from parents; favoritism of other children in the family. Parents scape-goat child in family group, focus problems on him, and encourage his i i so l a t ion . 185 Schedule B. continued Cri ter ia Explanation of Ratings A. Good B. Fair C. Poor 13. Family's  Relation-ship with  Extended  Family Parents have har-monious, mature relationships with paternal or mater-nal relat ives ; relationships with extended family a source of strength to the group. Some inter-rela-tionships problems between nuclear and extended fam-i l y which create problems within the group. Frequent and severe confl ict between nuclear and extended family, which places marked stresses on the group. 14. Family's  Relation-ships with  Community of Residence Good relationships with neighbours and institutions in community; ac-tive participation in community af fa irs , pation in community a f fa irs . Minimal contact with neighbours and community inst i tut ions ; minimal pa r t i c i -Hostile re-lations with neighbours and community inst i-tutions , or complete with-drawal from community. 15. Parent al  Attitudes  towards  Child's Problems Parents view child 's problems with rea l i s t i c and supportive concern for him, and continue to show warmth and affection des-pite symptoms. Parents view chi ld ' s problems largely in re-lat ion to their own needs; some withdrawal of support and affec-tion when symptoms appear; or mini-mization of chi ld 's d i f f i cu l ty . Extreme projec-tion of family problems onto the ch i ld , or denial of ob-vious d i f f i -culties the chile is experiencing. 16. Precipi-tating  Factors in Parents' Application Family crises other than chi ld ' s prob-lem, such as eco-nomic reverses, severe i l lness or death of family mem' ber, cr i s i s in mari-t a l relationship, move to new commun-i t y . Cris is in chi ld ' s behaviour, such as excessive with-drawal or acting out, intensif ica-- tion of school - problems. Referral by a community re-source who have recognized the chi ld ' s emo-t ional problems. 186 Schedule B. continued* C r i t e r i a Explanation of Ratings A. Good B. F a i r C. Poor 17. Parents' Attitudes  towards a PBsychiatric C l i n i c Co-operative i n keeping and using appointments and in permitting co-l l a t e r a l contacts; expectation of being helped; w i l l -ingness t o involve other family mem-bers . Parents show some resistance i n keep-ing and using appointments and in permitting c o l -l a t e r a l contacts; f e a r f u l of psych-i a t r i c c l i n i c s ; u n -r e a l i s t i c expec-tations of helping process. Extreme concern •about attending a p s y c h i a t r i c c l i n i c ; consis-tent pattern of lat e or broken appointments; r e f u s a l to allow c o l l a t e r a l con-t a c t s ; expec-t a t i o n of c r i t i -cism from the C l i n i c ; unable to involve other family members. 18. Parents' Understand-i n g of Treatment Goals Understanding of and p a r t i c i p a t i o n i n treatment goals, Help i s used con-s t r u c t i v e l y . Has d i f f i c u l t y i n grasping treatment objec-t i v e s , but attem-pts to follow suggested pro-gram, or f e e l s ambivalent about treatment goals. Unable to com-prehend goals, or to see the necessity f o r them. 19. Movement  in Child's  and Parents' Adaptation Marked improve-ment i n child's behaviour, family relationships and functioning. Some improve-ment i n child's behaviour and family r e l a t i o n -ships, but s t i l l obvious areas of d i f f i c u l t y . No improvement i n child's be-haviour and family relation-ships and functioning recorded. 187 Appendix C, Soeial j j istorv Outline INTRODUCTION "Psychiatric history taking i s not merely a process of collecting data. It i s a means of getting acquainted with the person who presents the data, i t i s not a cut and dried 'technique' but a t h r i l l i n g experience had by two people." This i s the way that Dr. Leo Kanner* describes the report which the referror submits in his attempt to convey his understanding of the child, his family, and their problem. It i s an organized record of the story which the family pours out to one who, having offered to help, listens i n a warm and encouraging manner. From this ' t h r i l l i n g experience' comes the family's willingness to use the resources of the Children's C l i n i c . The in t r i n s i c value of a written case history i s determined neither by i t s volume nor by the mass of detail which i t contains, but by i t s orienting function! Two foolscap size pages of digested data i s of more value than three or four such pages of unrelated d e t a i l . The rambling story given by the parents can be reduced to a concise, graphic account of the problem as i t faces the child, his family,and his community. The attached social-psychiatric history outline i s a suggested means of organizing and focusing data. For the novice i t i s an instrument in learning of what type of facts to be aware, and for the experienced person i t simply serves to suggest the four broad areas of interest basic to a psychiatric diagnosis—the problem, family background, personal history, and the referror's evaluation and plan. The novice may lean upon this outline as a guide to content, but never as a questionnaire or as a means of interviewing. These four headings should follow i n this sequence, providing a universal order to the writer as well as to the reader. I f one section i s more important than the others, i t i s the problem; a l l other data should be relevant to the reason for r e f e r r a l . * Kanner, Leo — 'Child Psychiatry : ; this i s the textbook in this field of medicine. 188 Appendix C. - continued. SOCIAL HISTORY OUTLINE A guide to preparation of Social Histories for the Children's Clinic of the Mental Health Centre. -NAME: BIRTHDATE: PARENTS: (FATHER) (MOTHER) (MAIDEN NAME) DATE WRITTEN: DATE OF EXAMINATION: STATUS: (Ward, non-ward, etc.) BIRTHDATE: BIRTHDATE: S,S. INDEX: ADDRESS: TELEPHONE: SOURCE OF REFERRAL: (By whom and how) PROBLEM: (l) As stated and seen by parentss child,.and any other closely involved persons. What help are they asking for? How long have parents, child, or others been aware of the problem(s)? How do they feel about.receiving help? (2) Social worker's/public health nurse's general picture of problem. Estimate client's awareness of the presenting problem and other problems seen by the social worker/public health nurse. Reason for referral to Clinic at this time. What specific help is desired by social worker/public health nurse. DATE OF PREVIOUS EXAMINATION AT CHILDREN'S CLINIC (formerly Child Guidance Clinic), P.M.H., ETC. (Child or relatives). HOME SETTING: FAMILY HISTORY Pertinent and brief descriptive material of present home setting — economic and community status| housing! persons in home. FATHER: (l) Identifying information — namej present agej place of birthj religion. (2) Social and cultural background — others in family, agesj father's description of paternal grandparents! father's estimate of his adjust-ment to family, school, religion, and social groups! extent of education work record, health! any serious illnesses or operations. (3) Family relationships — father's feelings about and relationship to child, to wife, to others in family. Father's attitude and contribution with regard to problem(s)! How does he handle it? 189 Appendix C . - continued. FAMILY HISTORY: (cont'd) (4) Pate«aal relatives— information pertinent to child and parents' adjustment. MOTHER: Information as for father (l), (2) and (3). (4) Maternal relatives — information pertinent to child and parents adjustment. MARITAL ADJUSTMENT: When, where and how did parents meet? Courtship; sexual adjustment. STEP-PARENTS OR FOSTER HOMES s As above with dates child was with them and reasons for leaving. Indicate and evaluate relationships, adjustment, and the meaning of the experience to the child. (In chronological order) SIBLINGS; Indentifying information — name; date and place of birth; religion. How do they f i t into the family, inter-per^onal relationships? DESCRIPTION OF DEVELOPMENT TO DATE: Mother's health, attitudes and feelings about child during pregnancy; method of delivery; length of labour; birth injuries (1) Eating: Method of early feeding. Method of weaning, any early feeding, or present eating difficulties. Food fads or fussiness. Indigestion or any indication of gastro-intestinal disorder. (2) Elimination: Method and attitudes in training child. Difficulties. Any indications of frequent constipation or diarrhea. Any incidents of enuresis. Soiling. Smearing. Any present unusual attitudes or habits regarding elimination. (3) Sexual development: Interest in sexual information. Any incidents of exhibitionism. Sex play. Masturbation or intercourse (describe,, including age and frequenc;'-, of such incidents). Extent of sexual knowledge. From whom obtained. Evidence of development. PERSONAL HISTORY DEVELOPMENTAL FACTS: Date, place of births Toilet training began: Teethed at: Talked at (words): Age weaned: Bowel control at: Walked at: (sentence formation): Bladder control at: 190 Appendix C. - continued. PERSONAL RTSTfiBV ( r.nnt *d):• Age of puberty. A t t i t u d e toward i t . I f menses e s t a b l i s h e d i s i t r e g u l a r ? P a i n f u l ? Has someone discussed puberty and sexual r o l e w i t h c h i l d ? Any i n d i c a t i o n of abnormal sexual behaviour? (4) P h y s i c a l development: Has p h y s i c a l growth been normal? Give i n c i d e n t s o f i l l n e s s , disease (ages) sequelae ( d i s a b i l i t y , etc.) Reactions of c h i l d and parents t o s e r i o u s i l l n e s s e s . D i s a b i l i t i e s . Operations and pr e p a r a t i o n of c h i l d f o r these (age). C h i l d ' s a t t i t u d e t o and estimate of present h e a l t h . Any over-compensation or over-concern. PERSONALITY AND APPEARANCE: P h y s i c a l d e s c r i p t i o n — any i n d i c a t i o n s of nervous h a b i t s | f e a r s ; d i s t u r b a n c e s of s l e e p ; r e c u r r e n t or s i g n i f i c a n t dreams. General p i c t u r e of the c h i l d ' s outstanding r e l a t i o n s h i p s and how he (she) uses these. How does he (she) handle f e e l i n g s and need such as anger, a f f e c t i o n , dependency i n r e l a t i o n t o h i s (her) c l o s e s t r e l a t i o n s h i p s . A t t i t u d e s to s c h o o l , t e a c h e r s , people i n a u t h o r i t y . I n t e r e s t and Recreation; adjustment to s o c i a l groups, employment, p a r t i c u l a r f r i e n d s of both sexes. Ambitions and g o a l s . Estimate of c h i l d ' s i n s i g h t , i n t e l l i g e n c e , humour. SCHOOL RECORD: Grade and teacher's, r e p o r t . Bureau of Measurements r e c o r d i f i n Vancouver. EVALUATION AND PLAN S o c i a l w o r k e r 1 s / p u b l i c h e a l t h nurse's e v a l u a t i o n of case from work done by the pres e n t i n g agency. E v a l u a t i o n of stren g t h s and weaknesses i n c h i l d , parents, and p a r e n t - c h i l d r e l a t i o n s h i p . What has been done? How frequent are the contacts? How strong i s the w o r k e r - c h i l d r e l a t i o n ? What methods have been t r i e d i n working w i t h c h i l d and pa r e n t ( s ) ? What has been t r i e d by f a m i l y members i n d e a l i n g w i t h problems? How s u c c e s s f u l ? What p o s s i b l e resources are there i n f a m i l y or community to help meet c h i l d ' s needs? What are w o r k e r 1 s / n u r s e 1 s suggestions f o r c a r r y i n g on from the point? Questions around which s o c i a l worker/public h e a l t h nurse would l i k e d i s c u s s i o n . ALL HISTORIES SHOULD BE SIGNED BY THE SOCIAL WORKER OR PUBLIC HEALTH NURSE AND FOUR  C0PI5S SUBMITTED TO THIS CLINIC. Appendix D. -SUGGESTED FORMAT FOE  "SUMMARY FOR CONSULTATIVE CONFERENCE" ( C l i n i c D i r e c t S e r v i c e Cases) IDENTIFYING INFORMATION: ( b r i e f o r i e n t a t i o n to the case) (a (b (c (d (e ( f (g (h Name of c h i l d . Age. P r e s e n t i n g problem (one sentence). Parents — name and age. Address. S i b l i n g s — name and age* School grade* School. 2. Reason f o r present conference: S i g n i f i c a n t changes and/or c r i s e s s i n c e l a s t conference ( b r i e f ) . 3. Previous examinations:- d a t e s . (a) D i a g n o s t i c t h i n k i n g : (1) C l i n i c a l f i n d i n g s ( b r i e f and p e r t i n e n t ) , ( i i ) Recommendations. 4. I n i t i a l casework p l a n : number of workers i n v o l v e d , treatment g o a l s : 5. s t a t i s t i c s : i n c l u d e number of i n t e r v i e w s , c o n s i s t i n g of i n t e r v i e w s , reasons f o r g a p s — e . g . , r e s i s t a n c e , i l l n e s s , g e o g r a p h i c a l f a c t o r s , e t c . I I . SUMMARY OF SOCIAL V.OriK CONTACT: Incl u d e : new m a t e r i a l , casework a c t i v i t y , movement In r e l a t i o n t o : (a) The i n d i v i d u a l — c h a n g e s i n h i s f e e l i n g s and a t t i t u d e s . (b) The family-changes i n r e l a t i o n s h i p s w i t h i n I t . (c) Adjustments o u t s i d e the home. I I I . POINTS FOR DISCUSSION: May Include: q u e s t i o n s , goals f o r the f u t u r e , e t c . * now c a l l e d "Progress Conference" Appendix E . - Closing Summary 192 GUIDE FOR CLOSING SUMMARY The C l o s i n g Summary i s a r e c a p i t u l a t i o n of the S o c i a l Worker's con t a c t with a c l i e n t and i n c l u d e s : - s t a t i s t i c a l data, f a c t u a l i n -formation p e r t a i n i n g to the c l i e n t , statement of problems and goals a t the p o i n t o f assignment, e v a l u a t o r y statements of case-work w i t h c l i e n t , reason f o r c l o s i n g , and i n d i c a t i o n of c l i e n t ' s g e n e r a l adjustment a t the p o i n t of c l o s i n g . The w r i t i n g of a C l o s i n g S v.rr mar y l s an aspect of Case Recording which i s c o n s i s t e n t with good p r o f e s s i o n a l s o c i a l work p r a c t i c e . Uses - (a) Present c l i e n t . W r i t i n g a C l o s i n g Summary c a l l s f o r c r i t i c a l t h i n k i n g >y the S o c i a l Worker p r i o r to t e r m i n a t i o n of c o n t a c t , and i s an a i d to the s o c i a l worker i n e n s u r i n g t h a t the needs and i n t e r e s t s of h i s c l i e n t are adequately served or planned f o r . The Summary may be used by Casework S u p e r v i s o r s i n the d i s c h a r g e of t h e i r r e s p o n s i b i l i t y f o r the n a t u r e , q u a l i t y and q u a n t i t y of casework s e r v i c e s rendered by the worker. Duty workers may r e f e r to the C l o s i n g Summary i n r e p l y to i n q u i r i e s from other agencies who may subsequently serve the c l i e n t s , and on reopening the same or new f i l e i n same f a m i l y . (b) Other c l i e n t s . There are aspects of l e a r n i n g i n the p r e p a r a t i o n and study of the C l o s i n g Summary which f u r t h e r the s o c i a l worker's knowledge i n the i n t e r e s t s of the next c l i e n t . The C l o s i n g Summary i s a r e s o u r c e f o r agency personnel who are engaged i n r e s e a r c h p r o j e c t s . 193 Appendix E . - continued. FORMAT Date of A p p l i c a t i o n : Date Intake Conference: Date D i a g n o s t i c Conference: Date Assigned Continued S e r v i c e : Date C l o s i n g Summary: 1. IDENTIFYING INFORMATION: (age and/or b i r t h d a y ; sex; f a m i l y c o n s t e l l a t i o n & economic Status) (one sentence probably s u f f i c i e n t ) . 2. REFERRAL AND PROBLEM: ( r e f e r r e d by whom and through whom?) ( b r i e f , s u c c i n c t statement of problem presented a t I n t a k e ) . 3. DIAGNOSIS. PROGNOSISf AND .TREATMENT PLAN: ( r e f e r to f i n d i n g s of C l i n i c team as they emerge from D i a g n o s t i c C o n ference). k. COURSE OF TREATMENT: ( i n c l u d e s w a i t i n g p e r i o d i n months; d i v i s i o n of workers; number of i n t e r v i e w s ; missed appointments; span of cont a c t ) * ( i n c l u d e : e f f e c t of w a i t i n g p e r i o d and t r a n s f e r of workers i n terms o f r e s i s t a n c e , d e t e r i o r a t i o n , p r o g r e s s ; - continued -194 Appendix E. - continued. - 2 -c l i e n t ' s use of casework; i l l u s t r a t e degree and d i r e c t i o n of movement or change; refer to Consultative Conferences and supervisory or casework conferences re changes of focus). 5. EVALUATION OF PRESENT SITUATION: (what achieved i n r e l a t i o n to problem presented and treatment plan, i . e . #2 and # 3 ; general statement of amount of e f f o r t expended, degree of conferring etc.; present factors in c l i e n t s ' external and internal en-vironment; evaluation of c l i e n t s ' present adjustment i n r e l a t i o n to his environment). 6. REASON FOR CLOSING; e.g. c l i e n t withdrew; "goals achieved"; "referred t o — " include relevant anticipatory note or recommendation i f c l i e n t returns, etc. Prepared by Recording Committee, May, 1955. See attached presentation by the Research Committee; — " i n t e r -pretation of C r i t e r i a for Measuring Movement i n Social Casework". 195 Appendix F. BIBLIOGRAPHY BOOKS Ackerman, N. W., The Psychodynamics of Family L i f e . Basic Books Inc. , New York, 1961. (Copyright, 1958). Ackerman, N. W. , Beatmen, F. L . , Sherman, S. N . , Eds f , Exploring the Base for Family Therapy. Family Service Association of America, New York, 1961. Alexander, F . , Ross, H . , Eds. , Dynamic Psychiatry. University of Chicago Press, Chicago, 111., 1957* B e l l , N. W., Vogel, E . F . , A Modem Introduction to the  Family. Free Press, Glencoe, I l l i n o i s , I960. Bernard, Jessie, Social Problems at Mid-Century. Dryden Press, New York, 1957. Boehm, Werner W., Objectives of the Social Work Curriculum  of the Future. (Vol. 1, Social Work Curriculum Study), Council on Social Work Education, New York, 1959. Caplan, Gerald, E d . , Prevention of Mental Disorders in  Children; Basic Books Inc. , New York, 1961. Geismar, L. L . , Ayres, B . , Patterns of Change in Problem Families,, Greater St . Paul Community Chest and Councils, Inc. , St. Paul, Minn., 1959. Hamilton, Gordon, Psychotherapy in Child Guidance. Columbia University Press, New York, 1948. Parad, H. J . , E d . , Ego Psychology and Dynamic Casework. Family Service Association of America, New York, I960. (Copyright, 1958). Perlman, H. H . , Social Casework. University of Chicago Press, Chicago, 111., 1957. 196 Appendix F. - Bibliography (continued) Richmond, Mary £ . , Social Diagnosis. Russell Sage Foundation, New York, 1917. Stone, J . L . , Church, J . , Childhood and Adolescence. Random House, New York, 1957. Voiland, Alice L . , Family Casework Diagnosis. Community Research Associates Inc. , New York, 1962. PERIODICALS Austin, L u c i l l e , "The Relationship between Family Agencies and Mental Health C l i n i c s " , Social Casework. Vol . 36, February, 1955. Coleman, J. V . , "Distinguishing between Psychotherapy and Casework", Social Casework. Vol . 30, June, 1949. Faucett, E. C , "Multi-Client Interviewing: A means of Assessing Family Processes", Social Casework. Vo l . 43, March, 1962. Parad, H. J . , Caplan, G . , "A Framework for Studying Families in Crises" , Social Work. Vol . 6, October, 1961. Perlman, H. H . , "The Role Concept in Social Casework: Some Explorations", Social Science Review. Vol . 35, December, 1961. Pollak, 0., Brierland, D . , "The Midwest Seminar on Family Diagnosis and Treatment", Social Casework. Vol . 42, July, 1961. Sherz, F. H . , "Multi-Client Interviewing: Implications", Social Casework. Vol . 43, March, 1962. Siporin, Max, "Family-Centred Casework in a Psychiatric Setting", Social Casework. Vo l . 37, A p r i l , 1956. Weiss, V. W., "Multi-Client Interviewing: An Aid to Diagnosis", Social Casework. Vol . 43, March, 1962. 197 Appendix F, - Bibliography (continued) PAMPHLETS Directory of Health. Welfare and Recreational Services in  Metropolitan Vancouver. Community Chest and Councils of Greater Vancouver Area, I 9 6 0 . Proposal for an Area Demonstration Pro.iect. Community Chest and Councils of Greater Vancouver Area, May, 1962. THESES Hawley, C. M . , Role. Stress and Social Casework Practice. Master of Social Work Thesis, University of Br i t i sh Columbia, 1961. McCallum, M. F . , Family Differentials in the Habil itation of Children with Brain Injuries. Master of Social Work Thesis, University of Br i t i sh Columbia, 1961. Varwig, R., Family Contributions in Pre-School Treatment of  the Hearing-Handicapped Chi ld . Master of Social Work Thesis, University of Br i t i sh Columbia, I960. 

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