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Role, stress and social casework practice : an assessment of the concepts of role and stress in relation… Hawley, Constance Margaret 1961

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ROLE t STRESS AND SOCIAL CASEWORK PRACTICE An Assessment of the Concepts of Role and Stress i n Re la t ion to a Sample of S o c i a l Casework P r a c t i c e , by CONSTANCE MARGARET HAWLEY Thesis Submitted i n P a r t i a l Fu l f i lment of the Requirements for the Degree of . MASTER OF SOCIAL WORK i n the School of S o c i a l Work Accepted as conforming to the standard required for the degree of Master of S o c i a l Work School of S o c i a l Work 1961 The U n i v e r s i t y of B r i t i s h Columbia In presenting this thesis in partial 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 representative. It i s understood that copying or publication of this thesis for financial gain shall not be allowed, without my written permission. Department of XAJJ^L. The University of British Columbia, Vancouver 8", Canada. i i TABLE OF CONTENTS Chapter 1. The "So c i a l Role Theory"—Endorsed i n P r i n c i p l e Page but Untested i n Practice New knowledge from the s o c i a l sciences. Responsi-b i l i t i e s of s o c i a l work profession. The Curriculum Study's proposals. Necessity f o r research. S o c i a l r o l e theory i n r e l a t i o n to trends i n casework theory and practice. Evalua-t i o n of theory by leading s o c i a l workers. General outline of s o c i a l r o l e theory. Concepts of r o l e , stress and problem and t h e i r components. Purpose, setting and scope of t h i s study. • 1 Chapter 2. Translating the S o c i a l Role Theory Into Practice Selection of case record material. The extent of analysis. Methodology f o r ap p l i c a t i o n of concept of stress by components and categories. Application of concept of r o l e by measurement on rating scales. Role performance c r i t e r i a , scoring of r a t i n g scales, r o l e performance charts. Assess-ments. • • 23 Chapter 3« Case-Application of the Concepts of Stress and  Role The c h i l d r e n and t h e i r parents. Presentation: case summary; schedules depicting sources of stress, value threatened, duration of stress, response to stress, major r o l e impaired, r e c i p r o c a l r o l e ; r o l e performance charts; assessment 35 Chapter k. The S o c i a l Role Theorv--Is I t a Useful Tool f o r  Assessment? Redefining purpose of t h i s t h e s i s . Limitations of study. Evaluation of a p p l i c a b i l i t y of theory to casework practice. Problems encountered. Evaluation on basis of improvement of services. 152 Appendices: A. Diagnostic Conference Notes (12 cases). B. Rating Scales Devised f o r t h i s Study. C. Measurement of Role Performance. D. S o c i a l History Outline Used at C l i n i c . E. Bibliography. SCHEDULES AND FIGURES IN THE TEXT (a) Schedules A-!' A 2 , A^ i i i Schedules (cont'd.) Page B l > B2> B3 c l > °2 B l » D2' D3 E l > E 2 , E3 'l« F 2, F3 G l> °2> ° 3 H l . H 2, H3 h> I 2 , h J i > J3 K i - K 2, K3 L i ' (b) Figures iv ABSTRACT Late i n 1959, the Council on S o c i a l Work Education published a t h i r t e e n volume study on the desirable objectives- of s o c i a l work education. In the volume on casework method , i t i s proposed that the concepts of " r o l e " and "stress" be used i n combination f o r the assessment.of c l i e n t s ' problems. Leading s o c i a l workers have expressed much i n t e r e s t i n these proposals but have agreed that extensive research and testing are necess-ary to bring the theory to the l e v e l of practice. This thesis attempts a contribution i n t h i s area, applying the " s o c i a l r o l e theory" empirically to a sample of s o c i a l casework practice. Such an evaluation must be made i n r e l a t i o n to the s o c i a l work profession's ultimate r e s p o n s i b i l i t y to the c l i e n t . The c r i t e r i o n : W i l l t h i s theory enable the s o c i a l worker to help the c l i e n t more e f f e c t i v e l y ? The sample group are twelve cases from the f i l e s of the Children's C l i n i c , Mental Health Centre, where both parents and ch i l d r e n receive treatment services. The s o c i a l functioning of the parents has been examined i n r e l a t i o n to the s o c i a l function-ing of the primary c l i e n t , the c h i l d . The case record material was f i r s t analyzed on the basis of the concept of s t r e s s , the attempt being made to i d e n t i f y a) the sources of st r e s s , b) the values threatened, c) the duration of stress, d) the response to str e s s , e) the major r o l e s impaired and f ) the r e c i p r o c a l r o l e s affected. The concept of r o l e was u t i l i z e d to describe and rate c h i l d and parents i n terms of a) performance i n major s o c i a l r o l e s and b) the interrelatedness of roles i n the family network. The degree of r o l e impairment was rated f o r the roles of husband, wife, father, mother, son or daughter, s i b l i n g , employee, student and member of community (for adults; or peer (for c h i l d r e n ) . Assess-ment and r e d e f i n i t i o n of the c l i e n t i n r e l a t i o n to h i s problem was then attempted f o r each case. This study has brought a number of a n a l y t i c a l features to l i g h t . There i s need f o r c l a r i f i c a t i o n of s p e c i f i c r o l e s , e.g., "employee,11 where there are i n t e r s e c t i n g r o l e s . S i b l i n g r e l a t i o n s h i p s require considerably more study. I t suggests the need f o r obtaining information regarding the adequacy of the c l i e n t and those i n h i s immediate r o l e network i n the early f a c t - f i n d i n g phase of treatment, i n such a way as to minimize a d d i t i o n a l resistance. I t also suggests the necessity of eliminating con-fusion i n the c l i e n t r o l e through a mutual understanding of the client-worker expectations i n the early stage of treatment. An important feature of the theory that must be considered i f i t i s to be put in t o practice, i s that the c l i e n t must be perceived not only i n terms of general emotional responses to stress e.g., "anxiety" but i n terms of how t h i s reaction has affected h i s s o c i a l functioning, i . e . , which roles i n h i s network of r e l a t i o n -ships are impaired and which threatened. i v ACKNOWLEDGMENTS The writer wishes to express her sincere gratitude to Dr. Charles McCann, of the School of Social Work for his constant encouragement and assistance i n the preparation of this thesis; to Dr. Leonard Marsh, of the School of Social Work for his helpful suggestions, and to Mr. Don Ricketts, Director of Social Services, Mental Health Centre, for his cooperation i n providing and checking the case record material and for taking the time to read and discuss the findings. ROLE. STRESS AND SOCIAL CASEWORK PRACTICE An Assessment of the Concepts of Role and Stress i n Relation to a Sample of S o c i a l Casework Practice Chapter 1 THE SOCIAL ROLE THEORY - ENDORSED IN JRINCIPLE  BUT UNTESTED IN HtACTICE The New Knowledge "This i s a per iod of ferment i n s o c i a l work. Old knowledge and o ld ways are being chal lenged. New knowledge i s f looding i n , new ways are being t r i e d . " 1 Much new knowledge that has p o t e n t i a l s i gn i f i cance f o r the s o c i a l work profess ion comes from work i n the s o c i a l sc iences , notably soc io logy . Unfortunate ly , but not s u r p r i s i n g l y , the new f indings and theor ies are not ready-made f o r use by s o c i a l workers, and the terminology i s frequent ly unfami l iar . Perhaps f o r these reasons, there has been a hesi tancy on the part of many s o c i a l workers to attempt to adapt these theories f o r use i n the s o c i a l welfare f i e l d . There i s a l so some apprehension l e s t acceptance of the new theories might mean d iscarding the o l d e r , more f a m i l i a r psychoanalytic theories which have proved so va luable . D r . Herman S t e i n , i n a t a l k to the Supervisors Confer-ence, Smith Col lege School of S o c i a l Work, had t h i s advice f o r s o c i a l workers with regard to t h i s new knowledge: The development, f i r s t of a l l , i s not a f a d ; when content i s re levant and important, i t has to be studied and not brushed on l i g h t l y . 1 H o l l i s , F lorence , "Contemporary Issues f o r Caseworkers," Smith Col lege Studies i n S o c i a l WorkT February, I960, p. 122. 2 We should have no i n t e r e s t i n subs t i tu t ing one jargon f o r another, or adding a new jargon. This i s content to be mastered and not a bundle of impressive terms and phrases to be added to our vocabulary. I t i s content to be approached with respect f o r i t s complexity and i t s c o n t r i -b u t i o n , and a lso i t s l i m i t a t i o n s . ! As profess iona l people dedicated to the betterment of soc ie ty , there i s no denying our r e s p o n s i b i l i t y to examine new knowledge c r i t i c a l l y to determine how i t can be useful f o r im-proving s o c i a l work techniques and f a c i l i t a t i n g the r e a l i z a t i o n of s o c i a l work goals . The s o c i a l worker's e th ics require that t h i s examination or evaluat ion be undertaken i n r e l a t i o n to h i s ult imate r e s p o n s i b i l i t y to the c l i e n t . Hi s c r i t e r i o n should be: " W i l l t h i s theory enable me to help the c l i e n t more e f f e c t i v e l y ? " This thes is i s p a r t i c u l a r l y concerned with the evaluat ion of one of the most c u r r e n t l y popular s o c i o l o g i c a l concepts, the  concept of r o l e . Role re f er s b a s i c a l l y to the way i n which an i n d i v i d u a l perceives himself and i s perceived i n r e l a t i o n to the expectations of soc ie ty . The concept has been widely used i n recent years i n the s o c i a l sc iences , e s p e c i a l l y i n s o c i a l psychology and socio logy. S o c i a l psychologists have general ly concentrated on group-re lated r o l e s , the r o l e of l e a d e r , he lper , idea-man, clown and so on, i n order to study group dynamics. S o c i o l o g i s t s have been more concerned with i n s t i t u t i o n a l i z e d r o l e s , those r o l e s i n our soc ie ty such as w i f e , mother, husband, 1 S t e i n . Herman D . , "Some S o c i o l o g i c a l Concepts In Casework P r a c t i c e , " Smith College Studies i n S o c i a l Work. February, 1959, P. 3 f a t h e r , p u p i l , teacher, f o r which there are prescribed behaviour patterns embodied i n law, custom, t r a d i t i o n or other norm. I t i s t h i s s o c i o l o g i c a l concept of s o c i a l r o l e which i s of most i n t e r e s t to s o c i a l caseworkers. Some e f f o r t has already been made to integrate t h i s concept with s o c i a l work theory. The C o u n c i l f o r S o c i a l Work Educat ion's Curriculum Study, d i rec ted by Werner W. Boehm, 1 recommended that t h i s concept be used conjunct ive ly with the 2 concept of s t r e s s , as a diagnost ic t o o l i n s o c i a l casework. The basic premise of the Study i s that the purpose of s o c i a l  casework i s to he lp the c l i e n t achieve more e f f ec t ive r o l e  performance and thereby improve h i s s o c i a l f u n c t i o n i n g . The concept of r o l e i s recommended as a means of viewing the c l i e n t i n terms of h i s s o c i a l func t ion ing . The concept of s tress i s suggested as a means of determining the cause of impairment i n r o l e performance. For the purposes of t h i s t h e s i s , these two concepts, used i n combination as proposed i n the Study, w i l l be re ferred to as the s o c i a l r o l e theory. Although t h i s terminology may have a r i n g of the new and the strange, s o c i a l workers have been concerned with the 1 Boehm, Werner W. , The S o c i a l Casewprk Method, i n . S o p i a l Work Educat ion ( V o l . X , S o c i a l Work Curriculum Study) , C o u n c i l on S o c i a l Work Educat ion , New York, 1959. 2 O r i g i n a l l y developed i n r e l a t i o n to the study of d i sease , t h i s concept has been used by s o c i o l o g i s t s i n the context of s o c i a l problems. See Jess ie Bernard, S o c i a l Problems at M i d - century, The Dryden Press , New York, 1957« If s o c i a l aspects of t h e i r c l i en t s* problems since the days of Beatr ice Webb i n England and the C h a r i t y Organizat ion Soc ie t i e s In America. The theory, however, appears to provide a sharpened and more c l e a r l y defined focus f o r s o c i a l work, i n the problems which a r i s e i n the i n t e r a c t i o n of man and h i s environment, :. i n man's s o c i a l f u n c t i o n i n g . Thus i s avoided the two extremes of a s p e c i f i c focus on man and h i s in t rapsych ic performance, or on man's environment, the whole wide world around him. Boehm has suggested that the theory would be p a r t i c u l a r l y useful i n two areas . F i r s t , as a means f o r c l a r i f y i n g problems amenable to casework he lp . Second, as a means f o r assessing the person i n r e l a t i o n to h i s problem. The theory has not been f u l l y accepted by the profess ion and i t s future status i s s t i l l uncerta in . Boehm was the f i r s t to s tress that i t i s h igh ly abstract and that considerable research and t e s t ing are e s s e n t i a l to br ing i t to the l e v e l of p r a c t i c e . To date , l i t t l e research has been done. This thes i s w i l l attempt an evaluat ion of the s o c i a l r o l e theory as a means f o r assessing the person i n r e l a t i o n to h i s problem. On t h i s b a s i s , the theory w i l l be appl ied to the assessment (or d iagnos t i c ) phase of casework prac t i ce and an attempt w i l l be made to redefine the c l i e n t and h i s problem i n terms of h i s s o c i a l func t ion ing . The purpose i s to determine whether s o c i a l r o l e theory can he adapted f o r p r a c t i c e , and i f so, whether i t w i l l meet the c r i t e r i o n of enabling caseworkers to help t h e i r c l i e n t s more e f f e c t i v e l y . 5 Before the theory as out l ined i n the Curriculum Study i s presented i n more d e t a i l , i t i s important to consider i t i n r e l a t i o n to the present trend of casework t h i n k i n g . Is the theory so d i f f e r e n t , so r a d i c a l ? Is i t d i a m e t r i c a l l y opposed to current trends? Or i s i t compatible with the trends of the 1960*s? S o c i a l Role Theory i n R e l a t i o n to Trends i n Casework Theory and Prac t i ce The s ign i f i cance of t h i s theory i s that i t defines new boundaries f o r the profess ion . I t i s not to be assumed that these boundaries w i l l forever more remain s t a t i c , f or such i s the ever-changing nature of our soc ie ty that the profess ion must remain f l e x i b l e to meet new needs which are constant ly a r i s i n g . But however f l e x i b l e a profess ion may be, i t i s s t i l l e s s e n t i a l that at any point i n t ime, i t have a c l ear d e f i n i t i o n of goals and objec t ives , of l i m i t s , of area of competence, of s p e c i f i c tasks which i t i s equipped to undertake. In recent years , there has been confusion and controversy w i t h i n the profess ion i t s e l f , as to i t s funct ions and purpose. A f t e r a review of s o c i a l work l i t e r a t u r e , Boehm came to t h i s conc lus ion: A c l e a r - c u t view or a general ly acceptable and accepted p o s i t i o n about the purpose of s o c i a l casework does not now e x i s t . The goal of s o c i a l casework has frequent ly been stated i n rather broad terms leaving considerable room for i n t e r -p r e t a t i o n . 1 1 Boehm, Werner W. , The S o c i a l Casework Method i n S o c i a l Work  Educat ion ( V o l . X , S o c i a l Work Curriculum Study) , Counc i l on S o c i a l Work Educat ion , New York, 1959, p. 13. 6 The p ic ture of man as a s o c i a l be ing , in f luenc ing and being inf luenced by h i s environment, has always been w i t h i n the range of v i s i o n of s o c i a l workers, but t h e i r focus has sh i f t ed back and f o r t h as new knowledge and new theories I l luminated f i r s t one part of the p ic ture and then the other. Before the turn of the century, s o c i a l workers, understanding l i t t l e of the meaning of behaviour, tended to th ink that moral de fec t s , i d l e n e s s , dr ink ing and gambling were the causes of poverty and thus attempts at r e h a b i l i t a t i o n were d i r e c t e d toward a behaviour reform of the des t i tu te c l i e n t , by personal v i s i t s , advice and d i r e c t i o n s to become independent. E a r l y i n the twentieth century, there was more under-standing of the s ign i f i cance of p h y s i c a l , s o c i a l and economic f a c t o r s , i l l n e s s , poor housing, low wages, economic d i s l o c a t i o n , and subsequently, much concern among s o c i a l workers with s o c i a l reform and s o c i a l l e g i s l a t i o n . This was the era of s o c i a l a c t i o n , of Jane Addams, E d i t h and Grace Abbott and others i n the United S ta tes , and Beatr i ce and Sidney Webb i n England. The s o c i a l a c t i o n fervour was fading by the F i r s t World War, and the science of psychology which was becoming more popular , l e d to increased i n t e r e s t i n persona l i ty development. Some of the wr i t ings of Mary Richmond about t h i s time could e a s i l y be i n -corporated i n t o the theory out l ined by Werner Boehm. S o c i a l casework. • • in add i t i on to i t s supplementary value i n other tasks has a f i e l d a l l i t s own. That f i e l d i s the development of persona l i ty through the conscious and comprehensive adjustment of s o c i a l 7 relationships, and within that field the worker is no more occupied with abnormalities in the individual than in the environment, is no more able to neglect the one than the other,1 This equilibrium was not long maintained. Sigmund Freud's writings were penetrating America. His theories about the organization, dynamics and development of the human person-ality caused a revolution in social work, thought and practice. Gordon Hamilton, who was then practising casework in the Eastern States, has written a colourful account of this period. She relates that Freud's theory of personality "burst like an atom, and the 'fall-out' from the explosion proved extremely frighten-ing to many people both in and out of the profession.11^ There was great controversy, but most social workers grasped the opportunity to learn psychoanalytic techniques. There were a l l sorts of cults—the analyzed and the unanalyzed, those who were being analyzed by the wrong people, and those who were dedicat-ed to therapy as opposed to analysis.k Indeed, social workers became so preoccupied with inner l i f e , with individual-centred therapy, as to almost lose touch with outer reality and the social factors with which social workers 1 Richmond, Mary E., What is Social Casework?, Russell Sage Foundation, New York, 1922, p. 98. 2 Hamilton, Gordon, "A Theory of Personality: Freud's Contribution to Social Work," Ego Psychology and Dynamic Casework;,, ed. Howard J. Parad, Family Service Association of America, New York, 1958. 3 Ibid., p. 14. h Hamilton, O P . c l t . , p. 27. 8 were most f a m i l i a r . S t e i n has re f erred to the per iod as "the p s y c h i a t r i c d e l u g e . " 1 In recent years , the trend has been away from the area of psychiatry to a cons iderat ion of man as a s o c i a l be ing , f o r now s o c i o l o g i c a l theory has begun to catch up with persona l i ty theory i n developing mater ia l of use to the caseworker. S t e i n points out: There i s no escape. The s o c i a l sciences are with us and we cannot look to psychiatry as a haven against these new winds that are blowing our way. They are blowing just as s trongly wi th in p s y c h i a t r y . 2 More and more frequent ly there have appeared references i n s o c i a l work l i t e r a t u r e to "soc ia l environment," "soc ia l f u n c t i o n i n g , " "soc ia l r o l e . " Helen Perlman has defined casework as "a p r o c e s s . . . t o help i n d i v i d u a l s cope more e f f e c t i v e l y with t h e i r problems i n s o c i a l funct ion ing ."^ There has been general agreement i n the f i e l d that s o c i a l work i s on the verge of a new per iod of development. Gordon Hamilton wrote i n 1958: The prac t i ce of s o c i a l work, inc lud ing casework, i s undergoing profound changes. S o c i a l work i s i n one of i t s most c r i t i c a l phases of reorganiza-t i o n and a s s i m i l a t i o n of new materials.^" 1 S t e i n , Herman D . , "The Concept of the S o c i a l Environment i n the S o c i a l Work P r a c t i c e , " Smith Col lege Studies i n S o c i a l Work f June, I960, p . 189. 2 I b i d . , p. 188. 3 Perlman, Helen H a r r i s , S o c i a l Casework,, The U n i v e r s i t y of Chicago Pres s , Chicago, 1957, p . If Hami l ton , op t c i t.y p. 35. 9 That t h i s new phase, l i k e a l l new phases, w i l l meet with res i s tance and const i tute a threat to the p r a c t i t i o n e r i s evident i n her fo l lowing statement: Those of us who have studied and fol lowed Freud , w i l l , I am sure , f i n d out what to ho ld o n t o . 1 Swithin Bowers, on the other hand, i s representat ive of that segment of the profess ion that i s welcoming the new s o c i o l o g i c a l concepts with more enthusiasm* There i s a change coming about i n s o c i a l work, a good and healthy change, a going back to s o c i a l work's o r i g i n a l emphasis on the fami ly and on the c r u c i a l s o c i a l r o l e s that ex i s t w i t h i n t h i s primary group and primary environment.2 But the need f o r sound, we l l - t e s t ed theories has a l so been acknowledged. Dorothy Fahs Beck, i n an a r t i c l e on the need f o r research , has w r i t t e n : A l l i n a l l , i t i s evident that i n the fami ly serv ice f i e l d we are s t i l l standing at the threshold of an unknown and scarce ly v i s u a l i z e d pioneer research task. Our too l s and guidel ines inc lude ne i ther we l l - formula t -ed hypotheses nor we l l - t e s ted instruments .3 W i l l the s o c i a l r o l e theory f i l l t h i s need f o r the 1 I p i d . , p . 36 . 2 Bowers, Swi th in . "The Future of S o c i a l Work," The S o c i a l  Worker T January, i 9 6 0 , p. 36 . 3 Beck, Dorothy Fahs , "Research Relevant to Casework T r e a t -ment of C h i l d r e n , " S o c i a l Casework,, February-March, 1958, p. 4 3 . 10 profession? W i l l i t permit , as Boehm hopes "a more e f f e c t i v e t r a n s l a t i o n i n t o p r a c t i c e of the often expressed s o c i a l work emphasis upon the psychosocia l s i t u a t i o n ? " 1 Swithin Bowers has pointed out that the s o c i a l r o l e performance of persons "is an area which i s of the greatest importance not only f o r the good of the i n d i v i d u a l but f o r the good of soc ie ty ." He adds: The measure of s o c i a l r o l e adequacy i s determined not s o l e l y by what i s good f o r the i n d i v i d u a l , but a l so by the good of the group ( p a r t i c u l a r l y the good of the fami ly group) , and by the good of s o c i e t y . 2 The journals of S o c i a l Casework and S o c i a l Serv ice  Review both devoted an i ssue to reviews and comments on the Curriculum Study by recognized leaders i n the s o c i a l work profes s ion , shor t ly a f t er the Study was publ ished. The a p p l i c a t i o n of s o c i a l r o l e theory to s o c i a l work p r a c t i c e met with general approval , but i t was r e a l i z e d considerable research and t e s t ing would have to be done. Helen Perlman, w r i t i n g i n the S o c i a l Service Review of December, 1959, pointed out: S o c i a l work must take account of the i n f i n i t e labors that w i l l be required i f we are to understand the concepts invo lved , gauge t h e i r r e c o n c i l a b i l i t y — 1 Boehm, O P . c i t . , p. 3 6 . 2 Bowers, op, c i t * , p. 3^. 11 or l a c k of i t — w i t h our present theory systems, f i l l i n and te s t out the s p e c i f i c , p r a c t i c a l d e t a i l s which f a l l — o r which may refuse to f a l l — u n d e r these broadly sketched ideas.1 Jeanette Regensburg, i n the January i960 i ssue of S o c i a l CaseworkT has w r i t t e n : The framework i s not to be viewed as a f i n a l product; much of i t w i l l undoubtedly be reformulated as experimental work proceeds. The choice of t h i s p a r t i c u l a r concept [ s o c i a l funct ioning] and of other concepts which l o g i c a l l y precede and fo l low i t , i s a matter f o r thorough t e s t i n g and r e s e a r c h . . . . Granted that there w i l l be much f loundering and t r i a l and error while fur ther study and research proceed, I suggest t h a t , even so, the gains of s o c i a l casework prac t i ce can be great.2 Since that t ime, there has been l i t t l e d i r e c t r e f e r -ence to the theory and i t would seem the profess ion i s awaiting the necessary tes t ing and research. I t may take some years before the value of the theory i s known, but i t i s the purpose of the wr i t er that t h i s thes is w i l l contr ibute to the important research task which challenges the s o c i a l work profes s ion . The s o c i a l r o l e theory i s so complex, that f o r the purposes of c l a r i f i c a t i o n i t i s necessary to review i t i n d e t a i l 1 Perlman, Helen H a r r i s , "A Review: The S o c i a l Work Curriculum Study ."Vo l . X , 'The S o c i a l Casework Method i n S o c i a l Work Educa-t i o n , ' §ociaLMSSS^SSLM§Si§Ki December, 1959, P. *+25. 2 Regensburg, Jeanette , "The Curriculum Study: Impl icat ions f o r the Prac t i ce of S o c i a l Casework," S o c i a l Casework. January, I960. 12 before proceeding f u r t h e r . Here i s the theory i n summarized form as presented i n the Curriculum Study. SQOiqJ, RoiLe, Theory: , ftenersq, QuttAfle, In the f i r s t volume of the Curriculum Study, "Objec-t i v e s of the S o c i a l Work Curriculum of the F u t u r e , " the goals and object ives of s o c i a l work are expressed: S o c i a l work seeks to enhance the s o c i a l funct ioning of i n d i v i d u a l s , s ing ly and i n groups, by a c t i v i t i e s focussed upon t h e i r s o c i a l r e l a t i o n s h i p s which cons t i tu te the i n t e r a c t i o n between man and h i s environment. These a c t i v i t i e s can be grouped in to three func t ions : r e s t o r a t i o n of impaired c a p a c i t y , prov i s i on of I n d i v i d u a l and s o c i a l resources , and prevention of s o c i a l dys funct ion .1 S o c i a l f u n c t i o n i n g , then, i s the basis of the r o l e theory, and s o c i a l funct ioning can be understood only by assessing the s o c i a l , somatic and psycholog ica l f a c t o r s and t h e i r combinations which determine the q u a l i t y of t h i s f u n c t i o n -i n g . Boehm has defined s o c i a l funct ioning as "the sum of the i n d i v i d u a l ' s a c t i v i t i e s i n i n t e r a c t i o n with other i n d i v i d u a l s and s i tua t ions i n the environment." Because s o c i a l funct ioning i s such a broad concept, f o r the purpose of ana lys i s i t can be broken down i n t o manageable 1 Boehm. Werner W . , Object ives f o r the S o c i a l Work Curriculum  of the Future ( V o l . 1, S o c i a l Work Curriculum Study) , C o u n c i l on S o c i a l Work Educat ion , New York, 1959, P. 9*» 2 Boehm, Werner W . , The S o c i a l Casework Method i n S o c i a l Work  Educat ion ( V o l . X , S o c i a l Work Curriculum Study) , C o u n c i l on S o c i a l Work Educat ion , New York, 1959, P. 9*+. 13 uni t s : s o c i a l r o l e s . I t i s the sum of the r o l e s ( e . g . , w i fe , mother, daughter, employee, neighbour) performed by a person. By viewing an i n d i v i d u a l i n terms of h i s s o c i a l r o l e s , we can deal with the major r o l e s , usual ly the: f a m i l y , school and employment r o l e s . We can determine which r o l e s are performed adequately and inadequately , and we can examine the e f f ec t of the i n d i v i d u a l ' s performance i n a given r o l e or r o l e s upon h i s performance of other r o l e s . In t h i s theory, S o c i a l r o l e describes the a c t i v i t i e s and tasks which an i n d i v i d u a l i s expected to perform by v i r t u e of h i s membership i n s o c i a l groups and h i s p a r t i c i p a t i o n i n s o c i a l i n s t i t u t i o n s . These tasks and a c t i v i t i e s are patterned and prescr ibed by s o c i a l norms, such as law, , custom, t r a d i t i o n , convention and others . The core idea of the theory, then, i s that s o c i a l casework's purpose i s to help the c l i e n t achieve more e f f ec t i ve r o l e performance and thereby improve h i s s o c i a l f u n c t i o n i n g . In the tenth volume of the Curriculum Study. which deals s p e c i f i c a l l y with the casework method, s o c i a l casework i s def ined. Th i s d e f i n i t i o n i s reproduced here i n f u l l because i t provides the general framework f o r the whole theory. S o c i a l casework i s a method of s o c i a l work which intervenes i n the psychosocial aspects of a person's l i f e to improve, r e s t o r e , mainta in , or enhance h i s s o c i a l funct ioning by improving h i s r o l e performance. Intervent ion occurs when the person, or members of h i s group or community, r e a l i z e that h i s r o l e performance i s hampered 1 Boehm, The S o c i a l Casework Method i n S o c i a l Work Educat ion , P. 97. Ik or threatened. The in tervent ion takes place through a pro fes s iona l r e l a t i o n s h i p between the worker and the person, and a lso between the worker and other i n d i v i d u a l s whose i n t e r -ac t ion with the person a f fec t s h i s r o l e performance. Since s o c i a l funct ioning i s the product of i n t e r a c t i o n among i n t r a p s y c h i c , somatic and s o c i a l f o r c e s , s o c i a l casework involves assessing the i n t e r n a l and s o c i a l f ac tors which impair or threaten the person*s r o l e performance and helping him to f i n d and use the somatic, psychic and s o c i a l resources at h i s d i s p o s a l , to e l iminate or reduce mal-funct ion and to enhance funct ioning i n s o c i a l r o l e s . 1 Concepts of R o l e , S t r e s s , Problem and Their Components In order to understand t h i s theory, i t i s necessary to explore i t s major components. The three concepts of r o l e , s tress and problem are defined and described on the fo l lowing pages. The nature of the mater ia l does not e a s i l y lend i t s e l f to a smooth and i n t e r e s t i n g manner of presentat ion , but the theory may be more r e a d i l y grasped i n t h i s form. Concept of S o c i a l Role I t has been pointed out that the goal of s o c i a l work has been es tabl i shed to be e f f ec t ive s o c i a l f u n c t i o n i n g , and i n t h i s t h e o r e t i c a l perspect ive s o c i a l r o l e s are viewed as uni ts of s o c i a l f u n c t i o n i n g . I t should be noted that although the a c t i v i t i e s and tasks described for s p e c i f i c r o l e s are def ined by soc i e ty , there i s a c e r t a i n amount of leeway permitted. There are many ways of performing standard r o l e s . Jess ie Bernard, 1 Boehm, op. c i t . , p p . kk-h5. 15 whose descr ip t ions of the concepts of r o l e and stress were used extensively i n the Study, s t i p u l a t e s : ,rWe are not to th ink of r o l e s . . a s r i g i d s t r a i t j a c k e t s . The concept of s o c i a l r o l e has a number of components. Ranee: r e f e r s to the s o c i a l l y accepted ways of s a t i s f y i n g needs. Role Expecta t ion: re f er s to the a c t i v i t i e s considered a p p r o p r i -ate f o r the r o l e i n the l i g h t of the s o c i a l norms which prescr ibe r o l e behaviour. There may be a discrepancy between a c t u a l r o l e performance and s o c i a l expectations of the r o l e . Role Percept ion: re fers to the way the r o l e i s viewed e i ther by the person performing the r o l e or by the r e c i p r o c a l person. P e r s o n a l i t y , c l a s s , cu l ture and caste may a f fec t the perception of the r o l e . Views and values of the reference group may a lso a f fec t r o l e percept ion. A s o c i a l r o l e must have a counterpart . I t cannot be performed alone. For example, the r o l e of husband ind ica te s a r e c i p r o c a l r o l e of wi fe , of employer, employee. This premise i s the bas is of the fo l lowing components. R e c i p r o c i t y : r e f er s to the r e l a t i o n s h i p s of r e c i p r o c a l r o l e s . The d e f i n i t i o n of the r e c i p r o c a l r o l e i s af fected by the c l a r i t y of the d e f i n i t i o n of the r o l e . I f the r o l e of mother i s not c l e a r , then the r o l e of c h i l d i s not c l e a r . Interrelatedness of Ro les : r e f e r s to the repercussion and 1 Bernard, J e s s i e , S o c i a l Problems at Midcentury, The Bryden Press , 1957, p . ^5. 16 ef fec ts of changes i n performance of one r o l e upon performance of other r o l e s . For ins tance , improvement or d e t e r i o r a t i o n of a person's performance as a worker may a f fec t h i s performance as husband and fa ther . The i n t e n s i t y of the repercussion and i t s scope may vary a good dea l according to the closeness of c e r t a i n s o c i a l r o l e s ( e . g . , parenta l and spouse r o l e s ) and i n r e l a t i o n to the capaci ty and motivat ion of the c l i e n t . Role Network; combines the concepts of r o l e in terre la tedness and r o l e r e c i p r o c i t y , and provides a view of the c l i e n t as an i n t e r a c t i n g uni t i n a system of r o l e s . I t r e f er s to a l l the c l i e n t ' s s o c i a l r e l a t i o n s h i p s . So impact of s tress on any r o l e may have repercussions of varying degrees upon a l l of the other r o l e s . I t r e f e r s not only to the severa l ro l e s the c l i e n t per -forms but a l so to the r e c i p r o c a l performance of those with whom he i n t e r a c t s . Determinants of Rolet I t i s i n t h i s component that we see the breadth of scope of the r o l e theory, f o r not only are the mani-f e s ta t ions of behaviour examined, but the causes: p h y s i c a l endowment and funct ion ing; ego f u n c t i o n i n g , comprising both i n t e l l e c t u a l and emotional f a c t o r s ; and s o c i a l f a c t o r s , the persons i n r e c i p r o c a l r o l e s , reference groups, s o c i a l resources , and l e s s tangible inf luences of p h y s i c a l , economic, p o l i t i c a l and i n d u s t r i a l circumstances i n the person's environment. Role-Related Problems Role Impairment: re f er s to the i n d i v i d u a l ' s i n a b i l i t y to perform adequately i n a given r o l e . Impairment of one r o l e may lead to 17 impairment of other r o l e s i n the network, thus i t may be both cause and e f fec t of s t re s s . For example, impairment i n the mother r o l e w i l l r e s u l t i n impairment i n the c h i l d r o l e . Role Confusion: may be the r e s u l t of l a c k of c l a r i t y i n the d e f i n i t i o n of the r o l e — a common problem i n today's dynamic soc ie ty . Class and geographic mobi l i ty complicate t h i s problem even f u r t h e r . As a r e s u l t , many people are never c e r t a i n what i s expected of them or what they may expect from others . Or confusion may r e s u l t from c o n f l i c t among r o l e s , f o r example, w i f e , mother and worker. Concept of Stress Th i s concept i s c l o s e l y r e l a t e d to the concept of s o c i a l r o l e , f o r s tress i s defined as a s i t u a t i o n which involves a threat to the performance of a s o c i a l r o l e or r o l e s . The term i s not used synonomously with the term "anxiety," for "anxiety" r e f e r s to the s tress r e a c t i o n . Stress can be analyzed i n terms of three components: s tress f a c t o r , value threatened and s tress r e a c t i o n . 1 Stress F a c t o r : r e f e r s to the threats which a r i s e w i th in the i n d i v i d u a l (phys i ca l or psycholog ica l ) or from the environment, w i th in h i s network of r o l e s or the s o c i a l system. The resu l tant r o l e impairment w i l l be an a d d i t i o n a l , secondary, source of s t r e s s . 1 Boehm, O P . c i t . , p. 106. 18 Va.Lue Threatened: k threat to any value may produce a s tress r e a c t i o n . The value may be objec t ive ly great or sma l l , but i t i s the subject ive value that determines, to some extent , the degree of r e a c t i o n . The value may be l i f e , property , s ta tus , appearance, s e c u r i t y , s e l f - r e s p e c t , and so on, but i t i s the meaning of the value to the person involved that i s most important. React ion to S t r e s s : These are the r e a c t i o n responses made by the i n d i v i d u a l with the goal of maintaining the l e v e l of s o c i a l funct ioning which ex is ted p r i o r to the occurrence of the s t res s . This r e a c t i o n may or may not produce problems, depending on the e f fect iveness with which the s tress i s e l iminated or a l l e v i a t e d . The i n d i v i d u a l ' s r eac t ion w i l l take place on several l e v e l s , p h y s i o l o g i c a l l y , emotionally or s o c i a l l y ( r o l e - r e l a t e d ) invo lv ing some impairment i n ro l e performance, thus a f f ec t ing the whole r o l e network. Boehm's hypothesis concerning s tress sets f o r t h the f o l l o w i n g : 1 1. S tress i s an i n e v i t a b l e aspect of l i f e . 2. Source of s tress can be i n t e r n a l , and. due to somatic or psycholog ica l f a c t o r s , or ex terna l , and due to environmental f a c t o r s , (phys ica l and s o c i o c u l t u r a l ) , and there can be a combination of a l l three . 1 Boehm, O P . c i t . t p. 109. 19 3. Regardless of i t s point of impact, s tress may a f f ec t the funct ioning of the persona l i ty i n any of i t s aspects , p h y s i c a l , emotional , mental, s p i r i t u a l , s o c i a l , — a n d may manifest i t s e l f through lowered performance i n one or severa l s o c i a l r o l e s . *K Because of r e c i p r o c i t y of r o l e behaviour and i n t e r r e l a t e d -ness of r o l e s , r o l e performance d i f f i c u l t i e s may themselves cons t i tu te a source of s tress which may further reduce performance i n the r o l e s so af fected and may a f f ec t per-formance of other r o l e s . This i s known as "secondary s t r e s s . " 5. Prolonged s tress i n one area or s tress a f f ec t ing severa l areas of funct ioning ( s o c i a l r o l e s ) can lead to extended r o l e breakdown, and, i n t u r n , to persona l i ty d i s o r g a n i z a -t i o n . However, s tress does not automatical ly lead to dysfunct ioning . 6 . Man tends to absorb s tress s i tua t ions through various types of defensive and adaptive responses i n an e f f o r t to maintain and e s t a b l i s h a dynamic equ i l ibr ium which expresses i t s e l f i n a c e r t a i n l e v e l mode of s o c i a l func t ion ing . 7. Major forms of adaptation are f i g h t or f l i g h t ( p h y s i c a l l y , psycho log ica l ly or s o c i a l l y or a l l three or combinations of thecttiree). 8 . The p h y s i c a l or psycholog ica l or combined responses a v a i l -able to the I n d i v i d u a l may not be adequate to cope with s tress and therefore s o c i a l in tervent ion from outside may be necessary. 20 9. These outside forces take the form of r o l e support and cons t i tu te widening of the r o l e network. Concept of Problem Problem i s defined as a person's response to s tress s i tuat ions which a f fec t s h i s r o l e performance i n such a way as to r e s u l t i n r o l e impairment. Such problems may be perceived by the i n d i v i d u a l , by someone i n h i s immediate r o l e network (mother, f a t h e r , s i s t e r , e t c . ) or by society ( schoo l , publ ic h e a l t h , p o l i c e , neighbours) . The person's degree of motivation to use casework serv ice w i l l depend, to some extent, on who perceived the problem and who decided pro fe s s iona l help was needed. I t i s probable that a person r e f e r r e d by the c o u r t , f or example, would not have as much motivation as a person who, aware of h i s own r o l e impairment, v o l u n t a r i l y sought he lp . Boehm w r i t e s : The concepts of s o c i a l r o l e and s tress used i n combination are suggested here as too l s f o r understanding and descr ib ing the t y p i c a l or core problems which come to the a t tent ion of the various f i e l d s of p r a c t i c e . 1 He sees the problem i n c h i l d wel fare , f o r ins tance , as the i n -adequate performance of the parental r o l e and i t s e f fects upon the r e c i p r o c a l r o l e of the c h i l d . 1 Boehm, Curriculum Study, V o l . X , p. 112. 21 Purpose, Se t t ing and Scope of This Study I t has already been noted that the purpose of t h i s study i s to apply the s o c i a l r o l e theory to the assessment (or d iagnos t i c ) phase of s o c i a l casework* The se t t ing chosen was the C h i l d r e n ' s C l i n i c , Mental Health Centre* A few words about the C l i n i c are ind ica ted at t h i s point to give an understanding of the source of the mater ia l used i n t h i s study* The C h i l d r e n ' s C l i n i c i s the place of the w r i t e r ' s f i e l d work placement and has been chosen p r i m a r i l y f o r the sake of the w r i t e r ' s convenience, but other advantages cannot be overlooked. Although the c h i l d i s considered "the c l i e n t , " services are extended to at l e a s t one parent , or parent - subs t i tu te . Therefore i n t h i s s e t t i n g , considerable information i s a v a i l a b l e concerning the c l i e n t ' s r o l e network. The C l i n i c , operated by the P r o v i n c i a l Mental Health Serv i ce s , i s the only n o n - r e s i d e n t i a l treatment centre f o r emotionally d is turbed c h i l d r e n on the B r i t i s h Columbia Mainland. I t i s a m u l t i - d i s c i p l i n e s e t t i n g , where p s y c h i a t r i s t s , psycholog i s t s , s o c i a l workers and nurses work together i n groups as teams. The admission procedure requires an intake interview with one or both parents , fo l lowing which an Intake Conference 1 i s he ld to decide whether the case should be accepted or r e f e r r e d 1 At the weekly Intake Conference, the intake worker presents the case to the appropriate team for dec i s ion as to d i s p o s a l . 22 to another agency. I f the case i s accepted, the s o c i a l worker holds four or f i v e in terv iews , usual ly with the mother, and at l eas t one with the f a t h e r , and on the bas is of information obtained, prepares a S o c i a l H i s t o r y . The c h i l d , i n the meantime, i s examined by the psychologist on the team, who administers the psychometric t e s t s . And f i n a l l y , the p s y c h i a t r i s t has an i n t e r -view with the parents and c h i l d , i n d i v i d u a l l y or together. Fol lowing t h i s pre l iminary i n v e s t i g a t i o n , the team meets f o r a Diagnost ic Conference and each team member presents h i s f ind ings and eva luat ion . I t i s at t h i s conference that i t i s decided what services can be offered the parents and c h i l d p and which fami ly members should be involved i n treatment. Although fur ther information about the c l i e n t ' s s o c i a l funct ioning i s sometimes revealed i n treatment in terv iews , and diagnosis must be an on-going process , we are us ing , f o r the purposes of t h i s study, the information about the c l i e n t and h i s r o l e network obtained p r i o r to the diagnost ic conference. The diagnosis or assessment^ as i t appears i n the case records , w i l l then be rewri t ten i n terms of the s o c i a l r o l e theory. Let us now turn to a d e s c r i p t i o n of the methodology of the study, which forms the body of the fo l lowing chapter . 1 See Appendix D for a copy of the s o c i a l h i s t o r y out l ine used at the C l i n i c . 2 See Appendix A f o r recording of the Diagnostic Conferences, taken verbatim from the f i l e s of the cases se lected for t h i s study. 3 The term "assessment," preferred by the wr i ter to "diagnosis'/ w i l l be used henceforth i n t h i s paper. Chapter 2 TRANSLATING THE SOCIAL ROLE THEORY INTO PRACTICE Leading s o c i a l workers have agreed with Boehm that t h i s theory i s h igh ly abstract and that much te s t ing and experimentation i s necessary before i t s value can be determined. There i s , however, no es tabl i shed plan to fo l low f o r t e s t ing purposes. Th i s chapter describes the method devised f o r t h i s study f o r applying the theory to the case record m a t e r i a l . The s e l e c t i o n of case m a t e r i a l , the scope of the study and the way ~»\ i n which the concepts or r o l e and s tress were appl ied to the i m a t e r i a l , are dea l t with i n t h i s chapter . Selegftipn, pf Cases In the f i r s t chapter , i t was explained that the case record mater ia l f o r t h i s project was taken from the f i l e s of the C h i l d r e n ' s C l i n i c , Mental Health Centre . To ensure that s u f f i c i e n t information would be a v a i l a b l e , i t was decided that the cases to be used must have been presented at a Diagnost ic Conference, and the Conference notes recorded i n the c l i e n t ' s f i l e . As some of the f i l e s contained a considerable amount of r e c o r d i n g , and time d i d not permit a thorough study of the records to date , the information f o r t h i s project was taken from the recording done p r i o r to the Diagnost ic Conference, This inc luded the intake worker's i n i t i a l interviews and sub-sequently, the s o c i a l workers interviews with the parents , the 2k psycholog i s t ' s reports of interviews with the c h i l d , and i n some cases , the p s y c h i a t r i s t ' s record of h i s interview with parents and c h i l d . I t a l so i n c l u d e d , i n some cases , information from previous r e f e r r a l s to the C l i n i c . The t r a n s c r i p t s of the Diagnostic Conference records appear i n the appendices to t h i s t h e s i s . As Diagnost ic Conferences are sometimes conducted several months a f t er a p p l i c a t i o n i s made to the C l i n i c , an a r b i t r a r y time l i m i t f o r app l i ca t ions was made. The time span se lected was from January 1 , I 9 6 0 to June 3 0 , i 9 6 0 , to ensure that Conferences had been he ld f o r a l l the cases by the commence-ment of t h i s study. There were about s i x t y app l i ca t ions made to the C l i n i c during t h i s p e r i o d , most of them being c a r r i e d to Diagnost ic Conference, and a fur ther s e l e c t i o n of cases was e s s e n t i a l . The fo l lowing c r i t e r i a were f i n a l l y adopted. 1 . A p p l i c a t i o n for serv ice was made between January 1 , I 9 6 0 and June 3 0 , I 9 6 0 . 2. A Diagnost ic Conference was he ld and a record of the Conference appears on f i l e . 3 . The c h i l d r e n were s i x years of age or older at time of a p p l i c a t i o n . 1 There were twenty-four cases to which the c r i t e r i a a p p l i e d . 1 Th i s provided that the r o l e of student could be inc luded i n the a n a l y s i s , i n most cases. 25 These were then l i s t e d by surname i n a lphabe t i ca l order , and every a l t ernate case was used i n t h i s study, thus assuring im-p a r t i a l s e l e c t i o n of case m a t e r i a l . In the twelve cases used, i d e n t i f y i n g data was omitted or d isguised as much as pos s ib l e . A l l names are f i c t i t i o u s . The Extent of the Analys i s The mater ia l i n these twelve case records seemed w e l l -sui ted to t h i s t e s t . E s s e n t i a l to any study of an i n d i v i d u a l ' s s o c i a l f u n c t i o n i n g , i s information about the performance of those persons with whom he i n t e r a c t s , and at the C l i n i c , both parents are usual ly interviewed. One of the requirements f o r treatment of a c h i l d at the C l i n i c i s that one, or i f at a l l p o s s i b l e , both parents a l so become involved i n treatment. In most cases , the mother was interviewed more frequent ly than the f a t h e r , but there was i n each case some reference to the a t t i tudes and behaviour of the f a t h e r . A more thorough study of the mater ia l ind ica ted the primary focus i s on the mother-chi ld r e l a t i o n s h i p , at l e a s t i n the beginning phase of treatment. The mother-chi ld r e l a t i o n s h i p , once r e f e r r e d to by Freud as the "smallest group," 3" has t r a d i -t i o n a l l y occupied an important place i n psychoanalytic theory. P s y c h i a t r i c s o c i a l workers, p a r t i c u l a r l y i n c h i l d guidance c l i n i c s , general ly begin the f a c t - f i n d i n g process with an 1 Heiman, M a r c e l , "The Problem of Family Diagnos is ," Neurotic  I n t e r a c t i o n i n Marr iage r ed. V i c t o r W. E i s e n s t e i n , Basic Books, I n c . , New York , 1956, p. 22*f. 26 explorat ion of t h i s r e l a t i o n s h i p . From another aspect , i t i s usual ly the mother who appl ies to the C l i n i c f or help with her c h i l d , and i t i s the c h i l d and h i s problems she often wants to t a l k about i n the f i r s t few interv iews . Poss ib ly f o r these reasons, there was l e s s information i n the records regarding the f a t h e r - c h i l d r e l a t i o n s h i p , husband-wife r e l a t i o n s h i p , c h i l d -s i b l i n g r e l a t i o n s h i p and p a r e n t - s i b l i n g r e l a t i o n s h i p . On the basis of the mater ia l a v a i l a b l e , i t was decided to apply the theory to the c h i l d and both parents , although information about many of the fathers was somewhat sketchy. Not enough information was a v a i l a b l e to analyze the performance of the s i b l i n g or s i b l i n g s i n many of the cases , although they do f i l l major r e c i p r o c a l r o l e s . Concepts of Role and Stress The next step was to apply the two concepts of r o l e and s t re s s . Information was c a r e f u l l y s i f t e d from the records regarding each c h i l d and parent 's s o c i a l funct ioning i n terms of r o l e s , as perceived by themselves, by others i n t h e i r r o l e network, and by the C l i n i c s t a f f . This d i d not , however, provide a very c l e a r p i c ture of the person's r o l e performance. A more f r u i t f u l approach seemed to be through the concept of s t re s s . In t h i s p s y c h i a t r i c a l l y - o r i e n t e d s e t t i n g , where the focus i s p r i m a r i l y on the psychologica l aspects of the c l i e n t ' s f u n c t i o n -i n g , there i s abundant mater ia l regarding the c l i e n t ' s mental, p h y s i c a l and emotional development. The case mater ia l was f i r s t analyzed, there fore , using the concept of s t re s s . 2 7 Concept of Stress In the Curriculum Study, the three component elements of the concept of s tress were defined as the s tress f a c t o r , the value threatened and the r e a c t i o n to s t re s s . When treatment i s to be a fac tor i n the assessment, the durat ion of s tress and m o d i f l a b i l i t y of s tress f a c t o r s must a l so be considered, accord-ing to the h y p o t h e s i s . 1 An analys i s was made on t h i s bas is f o r each parent and c h i l d . The s tress f a c t o r s , or sources of s t r e s s , which term w i l l be used i n t h i s paper, were genera l ly c l a r i f i e d i n the records , although not i n the order shown i n t h i s a n a l y s i s . The values threatened were not c l a r i f i e d , and i n a l l cases , the d e c i s i o n as to which value was threatened was a r b i t r a r i l y made by t h i s w r i t e r . The information on the reac t ion to s tress was interwoven throughout the case records , as i n the case of the sources of s t re s s . In most ins tances , the reac t ion seemed to be a cumulative response to a l l the stresses experienced by the person. Only o c c a s i o n a l l y , as with Frank F . , Case 6 , who s tar ted to wet h i s bed aga in , masturbate and have temper tantrums fo l lowing the b i r t h of h i s s i s t e r , was the reac t ion to s tress traceable to one major source. Even then, there were supple-mentary sources, f or h i s mother was depressed and anxious at that t ime, and h i s grandmother, who was t o i l e t - t r a i n i n g the c h i l d , was p a r t i c u l a r l y harsh . The response to s t r e s s , there fore , 1 Boehm, O P . c i t . , p. 109. 28 as shown i n the analyses , should be considered as a cumulative response to the stresses past and present. In the analyses , the sources of s tress and react ions to s tress were categorized by order of the major r o l e impaired. This was done with a view to making the mater ia l more presentable , and with the thought that i t must be integrated with the concept of r o l e . Concept of Role In the Curriculum Study, i n a sec t ion devoted to the impl i ca t ions of the s o c i a l r o l e theory f o r diagnost ic purposes, the fo l lowing statement appears: In order to assess and understand a person's r o l e performance, the worker needs to view t h i s r o l e performance against c e r t a i n norms. Diagnosis i s unthinkable without norms, but unfortunate ly , norms are not and cannot e x p l i c i t l y be stated i n a l l problem s i tua t ions coming to the a t tent ion of s o c i a l caseworkers. The determinants of r o l e performance are numerous - somatic, psycholog ica l and s o c i o c u l t u r a l . Standards of somatic or psycholog ica l funct ioning are more r e a d i l y a v a i l -able than standards of s o c i a l f u n c t i o n i n g . ! While we may accept the statement that e x p l i c i t norms are not a v a i l a b l e f o r a l l r o l e s , we cannot overlook the f a c t that there are c e r t a i n general expectations for the performance of major s o c i a l r o l e s , p a r t i c u l a r l y fami ly r o l e s , i n our soc ie ty . C u r r e n t l y a good dea l of a t tent ion i s being focused by s o c i a l 1 Boehm, O P . c i t . , p. 121. 29 s c i e n t i s t s on the fami ly system as an i n t e r a c t i n g network of r o l e s , with complementary r o l e expectations. D r . John S p i e g e l , a psychoanalyst with an i n t e r e s t i n the s o c i a l sc iences , has wr i t t en with respect to fami ly r o l e d i f f e r e n t i a t i o n : For example, an American middle-c lass wife tends to expect her husband to t r e a t her as an equal . She expects of her husband a good deal of i n -dependence, i n i t i a t i v e , and planning f o r future success i n h i s occupation, but i n h i s r e l a t i o n s with her and the c h i l d r e n she expects co-operat ion , sharing of r e s p o n s i b i l i t y , and i n d i v i d u a l cons iderat ion . R e c i p r o c a l l y , the husband expects h i s wife to he lp i n h i s plans f o r future economic and s o c i a l success, notably by putt ing h i s success goals above any personal career or occupational goals of her own, and by developing the s o c i a l and domestic s k i l l s s u i t -able to h i s p a r t i c u l a r occupational s t a t u s . 1 In a paper e n t i t l e d "Role D i f f e r e n t i a t i o n i n the Nuclear Fami ly ," D r . Morr i s Z e l d i t c h pointed out that i n our soc iety i t i s acceptable that the wife may supplement the fami ly income. Nevertheless , the American male, by d e f i n i t i o n , must 'provide* f o r h i s f a m i l y . He i s respons- i b l e f o r the support of h i s wife and c h i l d r e n . His primary area of performance i s the occupa-t i o n a l r o l e , i n which h i s status fundamentally inheres; and h i s primary funct ion i n the fami ly i s to supply an income, to be the breadwinner.2 Z e l d i t c h emphasizes that the father i s 'supposed* to remain the primary executive member i n the fami ly u n i t . Even i n the most 1 S p e i g e l , John P . . "The Reso lut ion of Role C o n f l i c t With in the F a m i l y , " A Modern Introduct ion to the Fami ly T ed. Norman W. B e l l and E z r a F . Voge l , The Free Press of Glencoe, 111., I960, p. 363. 2 Z e l d i t c h , M o r r i s , "Role D i f f e r e n t i a t i o n i n the Nuclear F a m i l y , " A Modern Introduct ion to the Fami ly , p. 336. 3 0 democratic f a m i l i e s , Z e l d i t c h s ta tes , the father has the balance of au thor i ty . While we may concede that the statement i n the C u r r i - culum Study i s correc t i n that e x p l i c i t norms are not a v a i l a b l e , there do seem to be some general ly accepted norms for major r o l e s . For an analys i s of case mater ia l using the concept of r o l e , the w r i t e r be l ieved that some technique for measuring r o l e performance would prove va luable . As was prev ious ly noted, the information on s o c i a l funct ioning taken from the records d i d not g ive too c l ear a p i c ture of r o l e performance. There-f o r e , the w r i t e r has formulated c r i t e r i a f o r each of the major s o c i a l r o l e s under cons iderat ion i n t h i s study,—husband, wi fe , f a t h e r , mother, son or daughter, s i b l i n g , community member, employee, student. On the bas is of these c r i t e r i a , r a t i n g scales were devised f o r the measurement of r o l e performance. (See Appendix 8 ) Some comment i s necessary here about the r o l e s and c r i t e r i a used. Three of the r o l e s , peer, community member, and student are genera l , not s p e c i f i c r o l e s , such as husband and wi fe . Each general r o l e has many facets of i n t e r a c t i o n with various r e c i p r o c a l r o l e s . For t h i s study, the r o l e , member of  community, includes the r o l e s of f r i e n d , neighbour, person i n a g r o u p , — i n f a c t , a l l the other r o l e s performed by an adul t out-side of f a m i l i a l and employee r o l e s . I t was not w i th in the scope of t h i s thes i s to explore the performance of each separate r o l e , but t h i s accumulation of r o l e s under the heading "member of 31 community" permitted measurement of the i n d i v i d u a l ' s s o c i a l behaviour, where adequate information was a v a i l a b l e . For the peer r o l e , the same r a t i n g scale was used. I t should be noted that although allowance was made for the f a c t that c h i l d r e n i n c e r t a i n age groups do not n a t u r a l l y grav i ta te to group a c t i v i t y , the c h i l d r e n i n t h i s study, a l l s i x years of age and o l d e r , were rated on t h i s a b i l i t y to p a r t i c i p a t e to some extent i n group p l a y , when such group play was provided at the Day Centre f o r C h i l d r e n , 1 the school , kindergarten or at other such se t t ings . The student r o l e would normally be a r e c i p r o c a l r o l e to teacher. However, f o r the purposes of t h i s study, the student's r e l a t i o n s h i p to other students was a l so taken i n t o cons iderat ion i n the c h i l d ' s o v e r - a l l performance i n school . So a l so was h i s academic progress , f o r i t i s assumed t h i s would inf luence h i s r e l a t i o n s h i p with the teacher and other students , and perhaps, with h i s parents . Therefore , the student r o l e c r i t e r i a are extended beyond the student-teacher r e l a t i o n s h i p . For c r i t e r i a f o r frusbanfl and fafrfter, r o l e s , the wr i t er r e f e r r e d to a thes i s w r i t t e n f o r the School of S o c i a l Work, U . B . C . , i n 1957, i n which the author, Betty Marie Morton, suggested c r i t e r i a f o r evaluat ion of performance i n the 1 A d a i l y group-therapy program he ld at the C l i n i c f o r those c h i l d r e n who may benef i t from group a c t i v i t i e s . 3 2 masculine r o l e , and to current l i t e r a t u r e , such as Ackerman's book, The Psychodynamics of Family L i f e . 2 I t w i l l be observed that one major area of shared experience between husband and w i f e , sexual adjustment, has been omitted from the c r i t e r i a . This g l a r i n g omission was decided upon because l i t t l e information was a v a i l a b l e about the parents' sexual adjustment. I t i s probable that the sexual aspects of married l i f e were discussed i n treatment in terv iews , but mater ia l f o r t h i s study was taken from the records up to and inc lud ing the Diagnost ic Conference, before treatment interviews had commenced. The s i b l i n g r o l e c r i t e r i a were formulated by the w r i t e r from her own knowledge and experience. There would seem to be a pauci ty of l i t e r a t u r e on t h i s subject . The employee r o l e i s used here to ind i ca te occupational performance. In the case of the two persons who are or have been self-employed (Mr. A. and Mr. L . ) , there i s no one r e c i p r o -c a l r o l e . Their performance was evaluated on the bas is of t h e i r t r a i n i n g and i n t e r e s t ( c r i t e r i a 2 and 3 ) . Scoring of the Rating Scales The r a t i n g scales were scored f o r each c r i t e r i a on the bas i s of Not Impaired = 0 , Moderately Impaired = 3 , and 1 Morton, Betty Mar ie , The Psychodynamics and Treatment of the  Male Partner i n M a r i t a l C o n f l i c t Cases , Master of S o c i a l Work Thes i s , U n i v e r s i t y of B r i t i s h Columbia, 1957, schedule k, 2 Ackerman, Nathan W . , The Psychodynamics of Family L i f e , Basic Books, I n c . , New York , 1958, passim. 3 3 Severely Impaired = 5« This allowed f o r intermediate ra t ings of S l i g h t l y Impaired and Extens ive ly Impaired, scores 2 and k r e s p e c t i v e l y . The t o t a l score for each i n d i v i d u a l on each scale was d iv ided by the number of c r i t e r i a on that s c a l e , providing an average f i g u r e . F r a c t i o n s were taken to the nearest whole number. The r o l e performance was computed as fo l lows: Measurement of Performance Not Impaired S l i g h t l y Impaired Moderately Impaired Extens ive ly Impaired Severely Impaired From t h i s information i t was poss ible to estimate how adequately each person performed i n h i s major r o l e s . The l i m i t a t i o n s of the mater ia l and of the rather p r i m i t i v e too l s make f o r a rough measurement, i t i s t r u e , but i t does provide some i n s i g h t i n t o the i n d i v i d u a l ^ s o c i a l func t ion ing . (See Appendix C) Charts Depic t ing Performance i n Ma,1or S o c i a l Roles The f i n a l step i n t h i s phase was the preparat ion of charts which portrayed the r o l e performance of each c h i l d and h i s parents . The purpose of the chart was not only to portray which r o l e s were impaired and which were not , and the degree of impairment i n the former, but a lso to portray the r e c i p r o c a l r o l e s , the in terre la tedness of r o l e s , and indeed, to give a Average Score 0 to 1 2 5 3 k pic ture of the c h i l d as an i n t e r a c t i n g unit i n a system of r o l e s . In t h i s t h e s i s , i t was not poss ib le to explore t h i s area very f a r , but i t could provide substance f o r extensive study. Assessments The ana lys i s of the case mater ia l on the bas is of the concepts of s tress and r o l e provided the data f o r the f i n a l phase of the t e s t , the formulat ion of an assessment. The assess-ment i s a r e d e f i n i t i o n of the problem i n terms of the s o c i a l r o l e theory. Chapter 3 APPLICATION OF THE CONCEPTS OF STRESS AND ROLE The C h i l d r e n and Their Parents This chapter presents the a p p l i c a t i o n of the s o c i a l r o l e theory to the twelve cases from the f i l e s of the C h i l d r e n ' s C l i n i c , Mental Health Centre . The case mater ia l i s analyzed i n terms of the concepts of s tress and r o l e , and the problem r e -def ined , i n the form of an assessment. A l i t t l e general information about the c h i l d r e n and t h e i r f a m i l i e s represented i n these twelve cases, might help bridge the gap between the abstract theory and the persons to whom the theory i s being a p p l i e d . There are three g i r l s and nine boys involved i n t h i s study, a l l of s i x years of age or over. The ir parents have presented a wide v a r i e t y of problems i n connection with t h e i r o f f s p r i n g : poor school progress , s t e a l i n g , antagonizing mother, temper tantrums, s o i l i n g , eneuresis , masturbation, unmanageable behaviour. The youngest c h i l d of the twelve i s s i x years of age, the o ldes t , f i f t e e n . The ir i n t e l l e c t u a l a b i l i t y var i e s from the superior range of general In te l l i gence to the border-l i n e range. The case h i s t o r i e s revea l a v a r i e t y of p h y s i c a l d i s a b i l i t i e s , — e p i l e p s y , s ight d i s o r d e r s , speech d i s o r d e r s , a l l e r g i e s and eczema. 36 In each of the twelve cases, the c h i l d i s l i v i n g with h i s n a t u r a l mother, and i n nine cases, with h i s n a t u r a l f a t h e r . In Case 3> the fa ther d ied several months before a p p l i c a t i o n was made to the C l i n i c ; i n Case 7 , the fa ther had died when the c h i l d was very young and the mother subsequently remarried; and i n Case 8 , the parents were recent ly divorced but the c h i l d s t i l l v i s i t s with h i s f a t h e r . In a l l cases, there i s at l e a s t one brother or s i s t e r l i v i n g i n the home. Only two of the mothers are employed outside the home (Cases 3 and 8 ) . The fathers are engaged i n various occupations ranging from labouring to profes s iona l work. One father i s unemployed, another doing post-graduate study at u n i v e r s i t y . These then, are the c h i l d r e n and the parents on which t h i s study i s focused. Although they dwell i n d i f f e r e n t geograph-i c a l areas , and move i n d i f f e r e n t s t ra ta of soc i e ty , each c h i l d and parent i s funct ioning i n r o l e s according to h i s b i o l o g i c a l grouping (age, sex) , to h i s status i n soc i e ty , to h i s s o c i a l adequacy acquired by growth and t r a i n i n g . A l l the c h i l d r e n have been brought to the C l i n i c because they are not meeting the expectations of at l e a s t one of t h e i r parents i n the performance of one or more major s o c i a l r o l e s . I t should be noted, too , that the prec ipat ing f a c t o r i n requesting service, has been, i n most cases , the parents' awareness that the c h i l d ' s perform-ance i s not meeting the expectations of soc i e ty , represented by the schoo l , the fami ly doctor , and i n one case, the l a n d l o r d . The c h i l d i s the primary c l i e n t , but because h i s r o l e network 3 7 embraces the r e c i p r o c a l r o l e s of mother and f a t h e r , t h i s t h e s i s , while not attempting a fami ly d iagnos i s , w i l l examine the parents' performance. In t h i s chapter the concepts of r o l e and s tress w i l l be appl ied to each of the twelve cases , and a r e d e f i n i t i o n of the problem w i l l be made on the bas is of the information so obtained. Presentat ion Each case w i l l be dea l t with separate ly . A short case summary with some pert inent data concerning the fami ly and the c h i l d ' s developmental h i s t o r y i s presented f i r s t . This i s neces sar i l y b r i e f and conc i se , and does not inc lude a l l the information on which t h i s study i s based. I t i s intended, however, to give a p ic ture of the c h i l d i n h i s fami ly s e t t i n g . Fol lowing the case summary i s a d e t a i l e d expos i t ion f o r each i n d i v i d u a l of the s tress f a c t o r s , values threatened, durat ion of s t r e s s , r eac t ion to s t r e s s , and r o l e s which are consequently impaired. This i s the "concept of stress" as de-f ined i n the Curriculum Study, appl ied to the s p e c i f i c i n d i v i -dua ls . In the cases where s u f f i c i e n t background information i s a v a i l a b l e , i t can be observed that one of the sources of s tress f o r the parents has been t h e i r e a r l i e r impairment i n the r o l e of c h i l d , a consequence of t h e i r parents' f a i l u r e to perform adequately i n t h e i r fami ly r o l e s . The r o l e performance chart which fol lows i s a graphic p o r t r a y a l of the "concept of r o l e . " I t depicts the major r o l e s 38 of the c h i l d , and of the parents , who are i n h i s Immediate r o l e network. I t shows the degree of impairment of major s o c i a l r o l e s , as measured on the r a t i n g sca les . And each chart depicts the r e c i p r o c i t y of r o l e s and interre latedness of r o l e s . An examination of the chart reveals how performance i n one r o l e can a f fec t performance i n other r o l e s i n the network. For example, i n Case 1, F igure 1, Mr. A.'s concentrat ion on h i s business career has s er ious ly af fected h i s performance i n the r o l e s of husband, fa ther and community member. 1 I t has a l so added to Mrs. A,'s d i f f i c u l t y i n moving from r o l e of employee to r o l e of mother. T h i s , i n t u r n , has af fected her performance as a wi fe . A lan ' s impairment i n the r o l e of son, a r e s u l t of h i s parents' poor performance i n t h e i r m a r i t a l and parenta l r o l e s , has caused extensive impairment i n h i s r o l e of s i b l i n g . As he has moved i n t o each new r o l e , h i s i n a b i l i t y to perform adequately i n other r o l e s has added to h i s s t re s s . By the use of t h i s concept, the c h i l d i s perceived not as an i s o l a t e d psycholog ica l s t r u c t u r e , but as a s o c i a l be ing, constant ly i n t e r a c t i n g with other s o c i a l beings , both inf luenc ing them and being inf luenced by them. I t i s a l so apparent that the concepts of r o l e and s t r e s s , i n combination, might w e l l be used as a t o o l f o r fami ly d iagnos i s . This w i l l be discussed fur ther i n the l a s t chapter of t h i s t h e s i s . 1 O r , i t i s poss ible that h i s i n a b i l i t y to perform w e l l i n these r o l e s has produced an overemphasis on h i s work r o l e . 39 I t i s important to note here that the in tervent ion of the C l i n i c i n the c l i e n t ' s r o l e network has provided an a d d i t i o n a l major r o l e , that of c l i e n t , f o r each of the persons involved i n treatment. The worker's entrance i n t o the c l i e n t ' s r o l e network has both p o s i t i v e and negative i m p l i c a t i o n s . On the p o s i t i v e s i d e , the c l i ent -worker r e l a t i o n s h i p i s fundamental to the problem-solving process . On the negative s i d e , i t im-poses a s tress s i t u a t i o n f o r the c l i e n t by fear of the new r e l a t i o n s h i p and i t s poss ib le impact on other r e l a t i o n s h i p s . 1 I f r o l e confusion e x i s t s , the s tress w i l l be m u l t i p l i e d and impairment i n the c l i e n t r o l e may be expected. This would ind i ca te there would need to be a s p e c i f i c attempt to c l a r i f y the mutual expectations of the c l i e n t and worker, and to recognize and resolve any di f ferences at an ear ly point i n the r e l a t i o n s h i p . This whole area of r o l e expectations seems to be r e l a t i v e l y unexplored. For t h i s reason, the r o l e of c l i e n t was not inc luded i n th:e: a n a l y s i s , but i t could provide a very f r u i t f u l area f o r experimentation and research. The Assessment of the c h i l d i n r e l a t i o n to h i s problem fol lows the r o l e performance chart . In each case, the wr i t er has attempted to redefine the problem by adapting the information contr ibuted by s o c i a l worker, psychologist and p s y c h i a t r i s t to the s tructure of s o c i a l r o l e theory. 1 Boehm, The S o c i a l Casework Method i n S o c i a l Work Educat ion , pp. 125 and 1M-3. ko In summary, the ensuing presentat ion cons is t s of twelve cases , each with a case summary, an i n t e r p r e t a t i o n of the concepts of s tress and r o l e , and an assessment. Parents Mr. A. Mrs, A. C h i l d r e n Alan B r i a n kl CASE I - ALAN A. Age 3 2 2 9 6 2 Occupation Student - Post-graduate course at U n i v e r s i t y Housewife Student - grade I R e f e r r a l by: Mother, because of Alan ' s poor f i r s t school r e p o r t . Presenting Problems: The mother thinks that Alan i s overact ive and that he does not play w e l l with other c h i l d r e n , and he i s not doing w e l l i n school . R a s e fo^a^y * Mr, and Mrs. A . and t h e i r two c h i l d r e n recent ly moved to the C i t y from the P r a i r i e s so that Mr. A. could e n r o l l f o r a post-graduate course at the U n i v e r s i t y . The fami ly i s under considerable f i n a n c i a l s t r a i n , but Mr. A . , a profes s iona l man, prev ious ly self-employed, hopes to obtain an adminis trat ive p o s i t i o n with a large organizat ion fo l lowing h i s graduation. Mrs. A . i s a s l i m , blonde woman appearing pa le , depressed, l i s t l e s s , who c r i e s e a s i l y but t r i e s very hard to c o n t r o l h e r s e l f i n f ront of her husband. Mr. A . i s a pleasant-mannered, dark, heavy-set man who does not show h i s f e e l i n g s . k2 They were married about eight years ago, shor t ly a f ter Mr, A . had f i n i s h e d h i s u n i v e r s i t y t r a i n i n g . According to Mrs, A . , he worked hard to b u i l d up h i s business and spent long hours away from home. Mrs. A. continued to work, f o r she enjoyed her o f f i c e job , and her husband was not yet f u l l y able to support them. Mrs. A . t o l d the worker that she was shocked to discover she was pregnant about a year a f t er marriage. Neither she nor her husband wanted a baby at t h i s time. She l e f t her job and stayed home f o r the next two years . Her husband often d i d not get home u n t i l l a t e i n the evenings, and Mrs . A, who had always been a f r a i d of the dark and depressed when l e f t a lone, was p a r t i c u l a r -l y unhappy during t h i s p e r i o d . Her husband d i d not want her to r e t u r n to work, but when Alan was two, Mrs . A. could no longer t o l e r a t e her s i t u a t i o n , so h i r e d a housekeeper and went back to her job. She worked f o r a year and h a l f , u n t i l she became pregnant with B r i a n . Since then, she has remained at home. Mr. A. has had l i t t l e time to devote to h i s f a m i l y , and Mrs. A. has few opportunit ies f o r recrea t ion or other i n t e r e s t s . Alan was born with a "wandering" eye, (a weakness i n the funct ion of the l a t e r a l muscles) , a condi t ion not yet correc ted . He has been wearing glasses s ince he was f o u r . As a small c h i l d , he had frequent colds and ear t r o u b l e . At the age of three , he was h o s p i t a l i z e d with mening i t i s , caused by neglected t o n s i l i n f e c t i o n . Three months l a t e r , he was h o s p i t a l i z e d f o r tonsi lectomy. At four he was sent to play school; but d i d not "*3 seem to enjoy t h i s experience. During h i s four th and f i f t h years he awakened every night with nightmares and crawled in to h i s parents bed - l i k e h i s mother, he i s a f r a i d of the dark; he has d i f f i c u l t y going to sleep and s t i l l wakens during the night qui te f requent ly , and goes in to bed with h i s parents . Mrs. A . t o l d the worker that during the time she was working, Alan was w e l l behaved with the housekeeper, but c r i e d when h i s parents l e f t f or work and screamed, ran around act ing s i l l y and babyish when she came home every evening. His behaviour d i d not improve a f t er B r i a n was born, and when he was four or f i v e , h i s mother d i s l i k e d him so much she "could have shaken the s tu f f ing out of h im." She has always found him l i v e l y and troublesome, but has been most concerned about him f o r the past two years . According to Mrs. A . , he demands constant a t t e n t i o n , never allows her to s i t down and read , never f i n i s h e s h i s meals, i s fussy about h i s food, i s rough with other c h i l d r e n , but at the same t ime, i s somewhat of a s i s sy and i s not very boy i sh . Alan loves h i s baby brother , according to Mrs . A . , and always kisses him before leaving f o r school , and at bedtime. Mrs. A. much prefers B r i a n , who i s quiet and easy to manage. Mr. A. a l so prefers B r i a n , although he i s not too concerned about A l a n ' s behaviour because h i s cousins were much l i k e A l a n . He does not th ink Alan i s feminine, but says he does seem very grown up and then acts i n a s i l l y , c h i l d i s h way. He f e e l s Alan has a good r e l a t i o n s h i p with B r i a n because he l e t s B r i a n push him around. Alan makes friends e a s i l y , but can't keep them because he becomes s i l l y and annoys them. He prefers adults, and w i l l t a l k with them i n a grown-up way. At school, the teacher thinks he i s lazy. He daydreams; w i l l s i t i n f r o n t of one piece of work a l l morning and not accomplish anything; brings h i s homework back undone, saying he d i d not f e e l l i k e doing i t . Towards the end of the term, he was d r i v i n g the teacher to d i s t r a c t i o n and she kept him i n v i r t u a l l y every night to f i n i s h h i s work. At the C l i n i c , according to the psychologist's report, Alan t e s t -ed i n the "very superior" range of general i n t e l l i g e n c e . In t e s t s , he proved s e n s i t i v e , angry, g u i l t y about h i s h o s t i l e f e e l i n g s . He f e e l s lonely and f r i e n d l e s s , unaccepted by other people. He also f e e l s l e f t out of the family because h i s parents favour Brian, and so i s intensely h o s t i l e to Brian. He displays such s i l l y attention-seeking behaviour that he provokes annoyance and further r e j e c t i o n . SCHEDULE kL, A 2, The A. Family Schedule A, - Mr. A. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-c a l Role Long working hours and r e l a t i v e l y small returns Success i n business, marriage 8 years Return to u n i -v e r s i t y for post-graduate work Husband Wife A l a n ' s b i r t h F i n a n c i a l s e c u r i t y , m a r i t a l r e l a t i o n -ship 6 years Displeasure with c h i l d Father Son Alan ' s a t t e n t i o n -seeking behaviour Father-image *+-5 years Annoyance with A l a n , obvious preference f o r B r i a n Father Son Schedule A 0 - Mrs. A. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-c a l Role Deprived childhood— f e l t she was unwanted, unresolved oedipal c o n f l i c t (?) Se l f - re spec t , secur i ty Since b i r t h Phobic f ear of dark, depress ions , depend-^ ency on other adults f o r protec t ion and companionship Threatens a l l ro le s Husband sees wife ' s r o l e as being that of homemaker Independence Since Alan ' s b i r t h H o s t i l i t y Wife Husband Alan ' s b i r t h plus her husband's expectations plus her dependency needs Freedom— opportunity for s o c i a l r e l a t i o n -ships 6 years Depression and r e -j e c t i o n of the c h i l d Mother Son Fami ly ' s f i n a n c i a l d i f f i c u l t i e s plus her dependency-host i l i ty Securi ty— mater ia l comfort 6 years Anx ie ty—addi t iona l h o s t i l i t y Mother Son Alan ' s s i l l y , babyish behaviour Mother-image h years G u i l t , h o s t i l i t y , r e -j e c t i o n , th inks she may have spanked Alan too much Mother Son Alan ' s problems i n school Mother-image, s o c i a l s tatus , family ego 6 mos. A p p l i c a t i o n to C l i n i c Mother Son Schedule A ^  - Alan A. Age 6 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-cal Role Mother's rejection Life, security, self-respect Since birth Generalized hostility and guilt—demands for attention and insecurity Son Mother Birth of younger brother Plus gener-alized hostility Place in family 2 years Additional demands for attention—hostility Son Mother Father's lack of understanding affection and his preoccupation with business plus Alan's insecurity Self-esteem, male identifica-tion Since birth Added hostility and insecurity, babyish-ness Son Father Parents' preference for Brian plus Alan's insecurity, hostility Self-esteem 2 years Hostility to Brian Sibling Sibling Demands of teacher plus Alan's in-security, hostil-ity Self-respect, achievement 6 mos. Demands teacher's attention—daydreams, does not work up to capacity, i s "driving teacher to distraction" Student Teacher Alan's insecurity and hostility Self-respect Since birth Demands attention from other children by same pattern of behaviour. Peer Peers C / V S E l X T H E A - FANULT Kit A- K R ^ A -V\odwa!Ce^Ii^ air e l - (ffl) Rot &\ou>v\. — ® F i C x - X T ^ F o K t A M A C G IN Wf\3"0£. 3 Q O A , L Kou t r^ . Assessment Cage, I Alan A,, a six-year-old boy, has reacted to stress by exhibiting s i l l y , demanding, babyish behaviour which has imparled h i s per-formance i n a l l major r o l e s . He has antagonized h i s parents to the point where h i s mother can barely t o l e r a t e him and h i s father i s generally annoyed with him. This behaviour has caused extensive impairment i n h i s performance i n h i s peer and student r o l e s . In h i s desire f o r acceptance, he reaches out to others, and according to h i s mother, he makes friends e a s i l y . However, when they cannot give him a l l the love he needs, h i s behaviour becomes even more demanding. He gains some attention i n a negative way from h i s teacher who keeps him at school v i r t u a l l y every night to f i n i s h h i s work. I n t e l l e c t u a l l y , he tested i n the very superior range of general i n t e l l i g e n c e . The o r i g i n a l source of stress f o r t h i s c h i l d i s r e j e c t i o n on the part of h i s mother who d i d not plan, and d i d not want to give up her r o l e of employee f o r the r o l e of mother. Her resentment has been directed mainly at Alan. Mr. A. expected her to remain i n the home, but was unable to give her the emotional support necessary to help her make t h i s adjustment. Her return to work, when Alan was two, increased the c h i l d ' s sense of r e j e c t i o n . Brian's b i r t h , when he was four, added to the stress. The parents' obvious preference f o r Brian has caused Alan to f e e l extremely h o s t i l e to him and to f e e l l e f t out of 50 the fami ly . This r eac t ion has resu l ted i n severe impairment i n h i s r o l e of s i b l i n g . The most modifiable fac tor i n the s i t u a t i o n would seem to be the time Mr. A. can devote to h i s fami ly fo l lowing h i s gradua-t i o n . I f h i s concentrat ion on business was a r e s u l t of h i s des ire to improve h i s f a m i l y ' s standard of l i v i n g , casework services could increase h i s awareness of the emotional needs of h i s wife and son, and may be of short-term nature. I f the r e s u l t of a sense of inadequacy i n the r o l e s of f a t h e r , husband and community member, casework cou ld , perhaps, serve to strengthen h i s performance i n these areas. Mrs. A . , i t appears, could benef i t from casework s e r v i c e s , p a r t i c u l a r l y d i rec ted to strengthening her performance i n the mother r o l e . A l a n , who must l e a r n a new pattern of behaviour so that he w i l l be more e a s i l y loved and accepted, has a problem which i s appropriate f o r casework serv i ce . When he has gained more s e c u r i t y , group a c t i v i t y might expedite the reeducation process. 5<t CASE II - BOB B . Parents Age Occupation Mr. B . ? Factory employee Mrs, B . ? Housewife - takes i n sewing to supplement income C h i l d r e n Bob Norman S a l l y Referred by: Mother, because of i n d i c a t i o n Bob may f a i l again grade I . Presenting Problems: Mr. and Mrs. B . are most concerned about Bob's poor school progress . Mrs. B . f e e l s that Bob does not seem to have any purpose i n l i f e , and that he i s very unhappy. He wet and s o i l e d u n t i l he returned to school t h i s year; s t i l l wets the bed occas iona l ly ; c r i e s e a s i l y ; masturbates. She says he does not get along with other c h i l d r e n of h i s age group, but plays with younger c h i l d r e n . He f i g h t s cont inua l ly with h i s brother . Case Summary: This fami ly l i v e s i n a new home i n a new subd iv i s ion . Mr. B . has been working at h i s present job f o r some years , and although 7 Student - grade I 6 2 h i s income i s steady, h i s wages are r e l a t i v e l y smal l . Mrs. B. earns a l i t t l e money by taking i n sewing. Finances are a con-cern to t h i s f ami ly . Mr. B . i s a dark, s l i g h t l y - b u i l t man, with a widespread b i r t h -mark, on h i s face . He f e e l s h i s appearance has been a tremendous disadvantage, that people are against him, that even h i s own family have treated him badly and that he has had a hard time i n l i f e . He has had seven sk in - gra f t ing operations which have p a r t i a l l y removed the birthmark, and c a r r i e s with him—for d i s p l a y — p i c t u r e s showing h i s countenance before and a f ter the operat ions . The psychologist noted that he had paranoidal tendencies . Mrs. B . i s t a l l e r than her husband and quite obese. She f ee l s Mr. B . ' s a t t i tude to people i s a r e a l problem f o r the f a m i l y . He c r i t i c i z e s her appearance, but she says she lacks the w i l l power to d i e t . He i s very s t r i c t with the c h i l d r e n , and when he straps them with h i s b e l t , she c r i e s with them. She admires h i s w i l l power, a b i l i t y to s t i c k to h i s dec i s ions and to save money. According to Mrs. B . , Mr. B . d i d not want c h i l d r e n and was quite d ispleased when h i s wife became pregnant. Mrs. B . who wanted c h i l d r e n was so concerned about her husband's a t t i t u d e , that she fed the f i r s t baby (Bob) every two hours on the twenty-four hour, to keep him quiet f o r her husband's sake. Bob was born with a congeni ta l h i p d i s l o c a t i o n , f o r which he 53 rece ived treatment for severa l years . At two years of age, a f ter various i l l n e s s e s , h i s eyes crossed, and he had two eye opera-t i o n s . In h i s ear ly ch i ldhood, according to h i s mother, "he was always s i c k and screeching." At the C l i n i c , the psychologist reported that Bob tested "low on the average range of general i n t e l l i g e n c e . " According to the psycholog i s t , he fears r e l a t i o n s h i p s and i s emotionally immature and d i s s a t i s f i e d . He a lso fears h i s parents and i s much con-cerned about spankings and punishment. SCHEDUIB B l f B2, The B. Family Schedule B, - Mr. B. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ip-r o c a l Role Severe f a c i a l birthmark Self-image Since b i r t h H o s t i l i t y — f e e l s at a disadvantage i n l i f e , d i s t r u s t f u l , susp ic ious , demanding of a t t ent ion Member of Commun-i t y Husband Comm-unity Wife Bob's b i r t h x>lus R e l a t i o n -Mr. B's need f o r ship with a t t en t ion wife 7 years Rejec t ion of c h i l d , harshness Father Son Bob's f a i l u r e i n school Family ego 1 1/2 years Involvement i n t r e a t -ment at C l i n i c Father Son Schedule B 0 - Mrs. B . Source of Stress Value Dhreatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role Her obes i ty Plus husband's c r i t i c i s m of her appearance Self-image ? Feel ings of inade-quacy, se l f -blame, re fers to h e r s e l f as "disgust ing, without w i l l power, soft", h o s t i l i t y to husband Wife Husband Husband d i d not want c h i l d r e n Mother r o l e Since marriage Host i l i ty—blames husband for some of c h i l d r e n ' s problems Wife Husband Bob's b i r t h plus her inadequacy f e e l -ings Marriage 7 years Anxiety and over-feeding c h i l d to keep him quiet f o r f a t h e r ' s sake Mother Son Bob's ear ly sickness, treatments, operation; e t c , , plus her s e l f -blame, g u i l t , f e e l -ings of inadequacy Mother-image M—5 years Inconsistent handling, overindulgence Mother Son Bob's f a i l u r e i n school Plus her gui l t , inadequacy, e tc . Family ego 1 year A p p l i c a t i o n to C l i n i c Mother Son Mr. B . ' s suspic ion and d i s t r u s t of other plus her f ee l ings of inadequacy Friendships ! Since marriage Withdrawal from s o c i a l r e l a t i o n s h i p s Member of Comm-uni ty Member of Comm-unity Schedule B-, - Bob B. Age 7 years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recip-rocal Role Mother's anxiety and feelings of ambivalence to him Security, self-esteem Since birth Feelings of i n -security, inade-quacy, hostile-dependency on mothei; sees her as a"direc-tive, unhappy person" Son Mother Early hip treatments, eye operations, i l l -nesses p lus his fear-fulness, insecurity Self-esteem 'Since birth Fearfulness, anxiety, h o s t i l i t y Son Mother Father's harshness Self-esteem Since birth ... Fearfulness, h o s t i l i t y Son Father Birth of younger brother plus his fear-fulness, h o s t i l i t y Place in family 6 years Hostility to brother, continual fighting Sibling Sibling Demands of teacher P lus his fearfulness Self-esteem, achievement 11/2 years Underachieving i n school,—failed grade I (does not read co-herently, goes blank) Student Teacher Fearfulness, feelings of inadequacy, etc. Self-esteem 3-h years Plays with children 2 - 3 years younger Peer Peers THE. B. FAMILY C O (N / \ f V \ O N \ l - - \ \-- -1-t -1 \ - -\ , / Mot l^cv^ovm'm^i^ole-O ® © F I G - . Z . i > ^ r o K » A ( \ N c ^ I N tAf\3o?. £ o c i / u . Roue:^ 58 Assessment Case II Bob B . , a seven-year-old boy, has reacted with fear and h o s t i l -i t y to the stresses imposed on him to an extent that h i s emotional and mental development have been stunted. His r eac t ion to s t re s s , has re su l t ed i n extensive impairment i n h i s performance i n the r o l e s of son, s i b l i n g , and peer and severe impairment i n the r o l e of student. Although he tes ted low i n the average range of general I n t e l l i g e n c e , he i s repeating Grade I and may f a i l again t h i s year . The sources of s tress have been h i s mother's anxiety and f ee l ings of ambivalence towards him because of her own i n s e c u r i t y and her husband's re luctance to share her with the baby; h i s f a t h e r ' s harshness; h i s ear ly h i p treatments, eye operations and other i l l n e s s e s , some of which were poss ib ly a l so a r e a c t i o n to s tress ; and the b i r t h of h i s brother when he was a year o l d . Intervent ion should be i n the s tress producing area , rather than i n the area of the c h i l d ' s r e a c t i o n to s t re s s . Casework services to Mrs. B. might be d i r e c t e d to developing her sense of s e l f -worth and adequacy and towards helping her be more consistent i n her handling of Bob. Mr. B . who has paranoidal tendencies , and i s performing poorly i n a l l major r o l e s , may require long-term treatment to strengthen h i s performance i n a l l areas , but p a r t i c u l a r l y i n the fa ther r o l e . 59 Concurrent with casework services to the parents, casework services would seem appropriate f o r Bob. k warm, consistent r e l a t i o n s h i p may help him overcome h i s fearfulness and move towards greater maturity. 60 Parents Mr. C . Mrs. C . C h i l d r e n C a r l Sam CASE I I I - CARL C . Age. (deceased i n 1959 at age 59) k2 Occupation Carpenter Part-t ime grocery c l e r k 13 12 Student - spec ia l c l a s s Student-Grade ? Referred by: Mother, f i r s t i n 1950 because of C a r l ' s speech impediment, again i n 1952 because of C a r l ' s v i o l e n t behaviour. He used a hammer on the bed-room door and chopped the asbestos covering on the furnace pipes with a hatchet . C a r l t o l d h i s mother that Sam committed these misdemeanours. Presenting Problem: Mrs. C . sa id she fears C a r l i s get t ing out of c o n t r o l . He has been dress ing up i n her c lo th ing and she fears sex attacks on other c h i l d r e n . He has become increas ing ly withdrawn and uncommuni-c a t i v e . She i s a lso concerned about h i s poor school performance. Case Summary: Mrs. C . i s a widow whose husband died suddenly f i v e months before she appealed to the C l i n i c f o r help with C a r l . A week af ter her husband's death, she took part-t ime work i n 6 1 a grocery store and i s now also taking n ight - schoo l courses. She hopes to re turn to f u l l - t i m e employment as a stenographer next year . Mrs. C . t o l d the worker that Sam, the younger boy, was sent to her brother ' s farm fo l lowing Mr. C . ' s death l a s t summer, but C a r l was kept at home. His mother needed him and thought he was p a r t i c u l a r l y upset. She sa id Mr. C . had always been very kind to C a r l and the boy was very dis turbed by h i s death. I t was during t h i s time when h i s mother was working and C a r l was home alone that he s tarted dress ing up i n her c l o t h i n g . Her brother subsequently came back to spend the winter months with the f a m i l y , but has recent ly returned to the farm. Mrs. C . i s present ly l i v i n g alone with the two boys. According to Mrs. C , C a r l has always been a source of concern. She and her husband, who had been d ivorced , planned to have t h e i r fami ly e a r l y , but a f ter ten years , f i n a l l y adopted a baby p r i v a t e l y . This c h i l d died at four months and about t h i s t ime, Mrs . C . became pregnant. C a r l ' s b i r t h was a very d i f f i -c u l t one. Labour continued t h i r t e e n hours and the baby's head and face were badly bruised by instruments. Mrs. C . was given drugs f o r i n f e c t i o n and t h i s so severely af fected the baby he near ly died but was revived by treatment i n an oxygen t ent . He had "stomach trouble" f o r the f i r s t s i x months. At one year , he ran a high temperature with what the doctor thought might be p o l i o . He had s tarted walking at t h i s t ime, 62 but regressed cons iderably , and d i d not t r y walking again f o r another few months. Sam's b i r t h , f o r which C a r l was not prepared, was a shock to the c h i l d . He c r i e d and h i d behind the c h e s t e r f i e l d when Sam was brought home from the h o s p i t a l . In 19501 when C a r l was f o u r , the fami ly doctor re f erred him to the C l i n i c because of h i s speech d i f f i c u l t i e s . Presumably, through some misunderstanding, Mrs. C , who had arranged an appointment with the intake worker on the phone, took the c h i l d to the Health Centre for C h i l d r e n . In t h e i r report on f i l e , the problem was diagnosed as "speech impairment and d r o o l i n g . " Phys i ca l f ind ings were negat ive . The speech therap i s t considered the d i f f i c u l t y was due to Mrs. C s anxiety and s i b l i n g r i v a l r y , but the p o s s i b i l i t y that C a r l was mentally defect ive was discussed with Mrs. C . Shor t ly a f t e r -wards, Mrs. C . had C a r l ' s tongue snipped ( i t was rather short) and t o n s i l s removed. In the next two years , when C a r l was four and f i v e , he had blackouts when he was f r u s t r a t e d or reprimand-ed. His fa ther descr ibed these as f a i n t i n g s p e l l s , with bubbling at the mouth. These had stopped by the time C a r l s tar ted school . In 1952, Mrs. C . again appl ied to the C l i n i c because of C a r l ' s poor progress i n Grade I . She a lso mentioned that he was nervous, stubborn, f e a r f u l of crowds, complained of headaches, and stomach aches. The psycholog i s t ' s report ind ica ted C a r l 6 3 showed confused behaviour, f e e l i n g of r e j e c t i o n by both mother and f a t h e r , l ack of sense of personal worth, h o s t i l i t y towards a l l members of the f a m i l y , and tested i n the "slow normal range of general i n t e l l i g e n c e . " The case was c losed a year l a t e r at the parents 1 request as the s i t u a t i o n had shown some improvement. Mrs. C . has had considerable i l l n e s s , "nervous breakdown," peptic u l c e r , sinus and other t roub les . She a t t r i b u t e d the ulcer to worrying about C a r l being "mental" when he was having so much speech d i f f i c u l t y . C a r l , now t h i r t e e n and a h a l f , i s i n advanced s p e c i a l c la s s ( for slow l e a r n e r s ) . His mother i s concerned about h i s poor school showing but even more concerned t h a t , a lone, she w i l l not be able to keep him i n c o n t r o l . At the C l i n i c , the psychologist reported that C a r l tes ted "in the border l ine range of general i n t e l l i g e n c e , " but i t i s thought that h i s p o t e n t i a l i s "slow normal." The psycholog i s t ' s t e s t s i n d i c a t e d a s i g n a l l ack of c o n t r o l . C a r l was diagnosed as a "character d isorder" type persona l i ty . SCHEDULE C x, C The C. Family Schedule C, - Mrs. C. Source of S t r e s s Value Threatened D u r a t i o n of S t r e s s Response to S t r e s s Major Role Impaired R e c i p r o -c a l Role Death of adopted baby Family s e l f -esteem ? Anxiety, f e a r f u l n e s s , g u i l t Mother Son C a r l ' s e a r l y i l l n e s s -es plus her a n x i e t y , g u i l t F a m i l y self-\3-k years esteem, ! Mother-image| A d d i t i o n a l a n x i e t y , over-p r o t e c t i o n Mother Son C a r l ' s speech d i f f i -c u l t y and suggestion of mental i l l n e s s Mother-image j Son's f u t u r e J ! 1 A p p l i c a t i o n t o C l i n i c (1950) Mother Son C a r l ' s poor s c h o o l progress, f e a r s , head and stomach aches Mother-image 6 mos. Son 1s f u t u r e j j A p p l i c a t i o n to C l i n i c (1952) Mother Son Husband's death S e c u r i t y , j 6 mos. home | Return to work, n i g h t s c h o o l c l a s s e s , a d d i -t i o n a l a n x i e t y Mother Son C a r l ' s d i s t u r b e d be-haviour - - d r e s s i n g i n her c l o t h e s , v i o l e n t a c t i n g out Mother-imageJ 6 mos. s e c u r i t y , 1 emotional j e q u i l i b r i u m j A p p l i c a t i o n to C l i n i c (I960) Mother Son Schedule C 0 - C a r l C . Age 13 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role Minor se izures (*t-5 years of age) , ear ly i l l n e s s e s , l e s s than average i n t e l l i g e n c e , protruding teeth Secur i ty , self-esteem Since b i r t h Confusion, h o s t i l i t y , f ear fu lness , inade-quacy 1 • 1 Son Mother B i r t h of younger brother His place i n fami ly 12 years A d d i t i o n a l f e a r f u l n e s s , h o s t i l i t y Son Mother Mother's anxiety re h i s being "mental" and her overprotec-t i o n Self-esteem 9 years A d d i t i o n a l inadequacy, h o s t i l i t y , confusion Son Mother Sam's s u p e r i o r i t y and r e j e c t i o n plus h i s i n f e r i o r i t y f e e l i n g s , h o s t i l i t y , e t c . Self-esteem 9-10 years H o s t i l i t y , r i v a l r y S ib l ing Sibling Demands of teacher, plus h i s i n f e r i o r i t y f e e l i n g s , confus ion, h o s t i l i t y , e t c . Self-esteem achievement 7 years Functioning below capacity Student Teacher 05 T H E . C . F A M I L Y W I F E CoN\Tv^UN \TV S I B U M C -Not Xxn-paiYci — O Sl%l\.tVj Ixrvpairecl tAolexatel^Xni'pafce . ElKtenswelvjXm^mrcl Sevieteiy Xtufaired -Not 1k^ottT\m£; 1?oU-® Not K-nouiu - © Fie-. 3 . -penz -^o-RrAANce \N JA^CTO^-. SOGIPVU R O U G ^ 67 Assessment Case I I I C a r l C , a t h i r t e e n - y e a r - o l d boy, i s d i sp lay ing extensive im-pairment i n h i s r o l e of son and moderate impairment i n h i s ro l e s of s i b l i n g and student. Nothing i s known about h i s r e l a t i o n s h i p with h i s peers but i t may be assumed that h i s r e a c t i o n to s tress which has caused impairment i n other r o l e s has af fected h i s performance i n t h i s area. He i s general ly immature and lacks s e l f - c o n t r o l . Psychometric tes t s give evidence of greater emotional disturbance than i s shown i n h i s r o l e performance. The c l i n i c a l diagnosis i s "character d i s o r d e r . " The o r i g i n a l source of s tress i n t h i s s i t u a t i o n was the mother's over-anxiety around t h i s c h i l d . (Her husband's des ire to have a f a m i l y , the long wait of ten years before C a r l ' s concept ion, the death of the adopted baby and C a r l ' s ear ly i l l n e s s e s a l l added to her a n x i e t y . ) Sam's b i r t h , when C a r l was one year o l d , was another source of s t re s s . He responded to these stresses by c l i n g i n g to h i s i n f a n t i l e behaviour. His mother's fears that he was "mental" fur ther added to the s tress imposed on him. C a r l ' s rather low i n t e l l e c t u a l capaci ty has not helped him cope with these s tresses . His jealousy of Sam, who i s br ighter and more outgoing, has fur ther complicated the s i t u a t i o n . The recent death of Mr. C . added to other stresses which were already overwhelming the boy, resu l ted i n fear of mascu l in i ty , as ind ica ted by h i s dressing i n h i s mother's c l o t h i n g . 68 Casework services f o r Mrs. C. may r e l i e v e some of her anxiety and may enable her to accept Carl's i n t e l l e c t u a l l i m i t a t i o n s . However, the other major sources of stress f o r C a r l cannot be modified by services to persons within h i s r o l e network. There-f o r e , the major area of intervention should be i n Carl's reaction to stress, which may involve long-term treatment f o r the boy. 69 CASE IV - DON D. Parents Mr. D. Mrs. D. C h i l d r e n Mary Doug Barry Mike Don ? ? Occupal^Qp Mechanic Housewife 22 21 ? ? 16 ( i n i n s t i t u t i o n f o r mentally defec t ive ) 15 6 Student - Grade ? Kindergarten p u p i l Referred by; Adult C l i n i c , where Mrs. D. had been rece iv ing treatment. Her diagnosis was "psychoneurotic r e a c t i o n , anxiety s ta te ." The p s y c h i a t r i s t at the Adult C l i n i c decided i t was Don's behaviour which was t r i g g e r i n g her anxiety . Presenting, Problems: Mrs. D. i s most concerned about Don's temper tantrums. She s a i d , too , that he i s bed wetting and n a i l b i t i n g . Case Summaryt Mrs. D . , described by the S o c i a l Worker as a shy sens i t ive woman, has never been very healthy and recent ly suffered a f a c i a l muscular contort ion which causes her to be even more s e l f -conscious. Mr. D . , a mechanic, described by the worker as shy, 70 s low-th inking , unsure of h imse l f , has had an e r r a t i c j o b - h i s t o r y . Shor t ly a f t er a p p l i c a t i o n to the C l i n i c , he was sent out of town by h i s employer f o r a six-months p e r i o d . Mrs . D. expressed much g u i l t about Don's d i f f i c u l t i e s , blaming herse l f because ne i ther she nor her husband had wanted another c h i l d , although she f e l t d i f f e r e n t l y about the baby a f ter he was born. Af ter the b i r t h of her f i r s t two c h i l d r e n , the doctor had sa id she should have no more c h i l d r e n . However, the contraceptive measures used were not success fu l , and Barry was born , mentally defec t ive . Mrs. D. has always f e l t responsible f o r h i s r e t a r d a -t i o n . Mike fol lowed the next year and then, ten years l a t e r , Don was born. Mrs. D. t o l d the worker t h a t , during her pregnancy with Don she was quite i l l . I t was a p a r t i c u l a r l y unhappy time, because she was a lso nursing an aunt who was dying of cancer. I t was a d i f f i c u l t labour p e r i o d , and she became exhausted and gave up halfway through the b i r t h process. The baby (Don) was h o s p i t a l -i z e d for the f i r s t month, and t h i s was fol lowed by intermit tent h o s p i t a l i z a t i o n s for the next year f o r bronch ia l congest ion. Mr. D. was a lso i l l at that t ime. Don has suffered from various a l l e r g i e s , and a small h e r n i a , a l l of which have caused h i s mother some concern. She has taken him to severa l doctors and a l l e r g i s t s i n the past few years . B a r r y , the son who i s i n the i n s t i t u t i o n , v i s i t s the home on week-ends. According to Mrs. D. he i s very fond of Don and 71 follows him around, touching him. Bon i s very f e a r f u l of Barry and becomes quite upset by h i s v i s i t s . Recently, since a l i t t l e g i r l undressed he r s e l f i n front of Don, he has exhibited behaviour which h i s mother thinks i s quite unusual. He w i l l not undress i n front of her, and must wear h i s bathing s u i t i n the bathtub. His mother fears he i s becoming "emotionally disturbed." At the C l i n i c , the psychologist reported that Don tested i n the "average range of general i n t e l l i g e n c e , " but i t was thought h i s p o t e n t i a l i s higher. In the psychometric tests he showed much concern about growing up and being masculine and independent. He s t i l l sees himself as a baby i n need of protection, who lacks s a t i s f a c t i o n and i s f e a r f u l of being hurt. The p s y c h i a t r i s t reported that there were three main areas of concern. F i r s t l y , h i s mother's need to see him as an i n f a n t ; secondly, h i s father's going away which gives Don's destructive f e e l i n g s toward father considerable force; and, t h i r d l y , h i s mother's concentration on h i s hernia condition which has aroused c a s t r a t i o n fears i n Don. SCHEDULE D x, D 2, D The D. Family Schedule D, - Mr. D. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role ? ? ? Very unsure of him-s e l f , shy, pass ive , dependent Husband Wife Schedule D« - Mrs. D. Source of Stress Value Threatened Duration of Stress Response to Stress Major. Role* Impaired Rec ipro-c a l Role Dependency on her mother Self-esteem Since b i r t h H o s t i l i t y , f ee l ings of inadequacy (mother helps her with housework but makes her f e e l i n f e r i o r ) Daughter Mother Husband's I n a b i l -i t y to give her adequate emotional and phys i ca l support plus her f e e l i n g s of inade-quacy Self-esteem, secur i ty Since marriage H o s t i l i t y , g u i l t Wife Husband B i r t h of mentally defect ive son Barry e s p e c i a l l y a f t er doctor t o l d her she should have no more c h i l d r e n Self-esteem, mother-image 16 years G u i l t — f e e l s responsible for Barry ' s r e tardat ion Wife Husband Donald's a l l e r g i e s and hernia Mother-image 2-3 years Guilt—"has hust led him around to a host of doctors and a l l e r g i s t s " Mother Son Donald's temper tantrums, demand-ing behaviour, plus her g u i l t f e e l i n g s , e tc . Emotional equi l ibr ium ? A p p l i c a t i o n to Adult C l i n i c (psychosomatic symptoms, fears she w i l l lose her temper—anxiety reac t ion Mother Son Schedule D-, - Don D. Age 6 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role Mother's ambivalence toward him Self-esteem, securi ty Since b i r t h Anxiety , anger, i l l n e s s Son Mother E a r l y h o s p i t a l i z a t i o n s plus h i s i n s e c u r i t y , anxiety Securi ty 1 year Fearfu lness , host -i l i t y Son Mother B a r r y ' s weekend v i s i t s plus h i s f ear fu lness , anx ie ty , e tc . Secur i ty Since b i r t h Fearfulness ? ? Awareness mother wish-es he were a g i r l and her concern over h i s hernia plus h i s f e a r -f u l n e s s , anxiety , etc . Mascul in i ty 2-3 years A d d i t i o n a l f e a r f u l ness, regres s ion , c a s t r a t i o n anxiety - .Son Mother L i t t l e g i r l ' s exposure plus h i s f ear fu lnes s , c a s t r a t i o n fears Mascul in i ty 6 mos. A d d i t i o n a l c a s t r a -t i o n anxiety (must wear bathing s u i t i n bathtub) Son Mother C A S E 4- T H E . J>. F A M I L Y Not Imyaircl — O Moietalel^ llmfa\rccl-(IS3*) S e u e r e L ^ I i u ' p a m v - l -H o t - p e t ^ Q r t a ^ H o l e <S Mot Kuoum - ® FlG-. -4" T E ^ r o ^ l A M ^ c e JN rAAJofc SOCIAL R O U E ^ 76 Assessment Case IV Donald D., a six-year-old boy, i s moderately impaired i n h i s r o l e s of son and s i b l i n g . L i t t l e i s known of h i s performances i n other r o l e s but he seems to be " s e t t l i n g down i n kinder-garten," according to h i s mother. His response to stress has been an e f f o r t to maintain the i n f a n t i l e r e l a t i o n s h i p to h i s mother. He i s concerned about growing up, and becoming i n -dependent. His fear of undressing even while i n the bathtub indicates concern about h i s masculinity. The sources of stress have been Mrs. D.'s ambivalence towards him and her consequent d i f f i c u l t y i n helping him mature normally. Her i l l - c o n c e a l e d desire f o r him to have been a g i r l , her con-cern over h i s hernia, and the l i t t l e g i r l ' s exposure have aroused serious c a s t r a t i o n fears i n the c h i l d . His father's inadequate performance i n h i s r o l e s as father, husband and employee, has-aggravated the stress t h i s c h i l d i s experiencing. The major area of intervention would seem to be required i n the stress-producing a r e a — t h e inadequate parental,role performance of Mr. and Mrs. D. However, as Mr. D. i s leaving town f o r some months (which w i l l further i n t e n s i f y the stress) casework services might be provided f o r Donald to help him react to stress i n a more p o s i t i v e way, and to strengthen h i s masculine i d e n t i f i c a t i o n . Casework services f o r Mrs. D. might be directed at achieving a more s a t i s f a c t o r y r e l a t i o n s h i p with her mother, 77 and could give her the emotional support lacking i n her marital r e l a t i o n s h i p so that she can allow Donald to move towards greater maturity. 78 CASE V - EVA E. Parents Age Occupation Mr. E. k7 Labourer Mrs. E. kO Housewife Children Ralph 19 Unemployed Sue 18 Married, 1 c h i l d Eva 11 Student, grade V Harry 6 ? Referred by; Mother i n 1952, at suggestion of worker at Gordon Neighborhood House, because of Eva's violence towards other c h i l d r e n and again i n i 9 6 0 because of Eva's l a s t unsatisfactory school report. Pre sent; i ^ g Problems: Mrs. E. i s most concerned about Eva's lack of i n t e r e s t i n school. She tackles new subjects with enthusiasm but soon loses i n t e r e s t . According to Mrs. E., Eva i s very s e n s i t i v e and very la z y . Case Summary: This family has experienced a good deal of i l l n e s s and f i n a n c i a l i n s e c u r i t y . Mrs. E. was i n h o s p i t a l three times t h i s past year and Mr. E. once, f o r a hernia operation. I t was during her 79 father's i l l n e s s that Eva's school marks f e l l so badly. She to l d the p r i n c i p a l that she was a f r a i d her father would never get out of the h o s p i t a l . Mrs. E. was perceived by the worker as the d i s c i p l i n a r i a n i n the family. She described her husband as "too soft and too easy." He seldom scolds Eva and has spanked her only twice. According to information given by Mrs. E., worry, sickness and in s e c u r i t y have been predominant i n t h i s home. Both parents come from broken homes. Mr. E. the youngest of ten chi l d r e n , l e f t school at fourteen, when his father died. He has no special s k i l l or t r a i n i n g and h i s work hi s t o r y has been e r r a t i c . Mrs. E. said her home l i f e was very unhappy. Her father argued constantly with her mother, b u l l i e d the children and deserted them when she was eleven. Her mother subsequently entered into a common-law r e l a t i o n s h i p , about which Mrs. E. i s embarrassed. Eva was a s i c k l y baby, who was h o s p i t a l i z e d four times i n her f i r s t year f o r a bronchial condition. She had her t o n s i l s removed at th i r t e e n months, and afterwards had attacks of bro n c h i t i s , mumps, measles, whooping cough, infected ear drums. During t h i s period, the family moved frequently and Mrs. E. re c a l l e d she was upset and confused. Her mother, who stayed with them frequently, was very s t r i c t with Eva. Eva, at two and a h a l f , was attacking other children with s t i c k s 80 and stones at every opportunity. Her mother took her to a play group at Gordon House, but Eva hated t h i s . The s o c i a l worker at Gordon House referred Mrs. E. to the C l i n i c i n 1952, because of Eva's v i o l e n t behaviour. Investigation at that time showed Eva was also b e l l i g e r e n t and c o n t r o l l i n g at home, was smearing, swearing, and causing general disorder i n the house. Mrs. E. f e l t she was beyond con t r o l . The p s y c h i a t r i s t analyzed the problem as severe separation anxiety with the mother's own emotional problems complicating the s i t u a t i o n . Eva then tested i n the "superior range of general i n t e l l i g e n c e . " The case was closed i n 195*+ eighteen months l a t e r , when some improvement was noted. Eva i s now i n grade V, and has been having trouble with her school work f o r some time. According to the school p r i n c i p a l , she seems unable to concentrate, and was given remedial courses which d i d not help her, and was f i n a l l y placed i n a slower group, which she resents. Her mother noted that she i s quite tomboyish, and prefers to play with boys, but her parents are not concerned with t h i s aspect of her behaviour. At the C l i n i c , the psychologist reported Eva tested i n the "average range of general i n t e l l i g e n c e . " In psychometric tests she proved immature and insecure, d i s s a t i s f i e d with h e r s e l f and with l i f e i n the family. SCHEDULE E x , E 2 , The E. Family Schedule E , - Mr. E . Source of Stress Value Threatened Durat ion of Stress Response to Stress Major Role Impaired Recipro c a l Role F a t h e r ' s ear ly death, Mr. E . ' s lack of educa-t i o n and t r a i n i n g Secur i ty - -Since boyhood Insecur i ty , withdrawal , frequent unemployment Employee Employer Mrs. E . »s concern for achievement, s o c i a l s ta tus , plus h i s f e e l -ings of i n s e c u r i t y Self-esteen Since marriage Withdrawal, p a s s i v i t y (does not d i s c i p l i n e c h i l d r e n , set l i m i t s , or give them emotion-a l support) Husband Wife E v a ' s behaviour—poor school performance ? ? Involvement i n t r e a t -ment at C l i n i c Father Daughter Schedule E 0 - Mrs. E . Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired R e c i p r o -c a l Role F a t h e r ' s b r u t a l i t y and d e s e r t i o n , mother's common-law r e l a t i o n s h i p Self-esteem, secur i ty Since ear ly childhood Fee l ings of i n -s e c u r i t y , inade-quacy, overconcern about what people th ink Threatens a l l r o l e s Mr. E . ' s pass ive , wi th-drawn behaviour—fai lure to give her adequate emotional support plus her i n s e c u r i t y Secur i ty Since marriage H o s t i l i t y , a d d i -t i o n a l i n s e c u r i t y , dominating be-haviour Wife Husband Mr. E . ' s f a i l u r e to succeed plus her insec -u r i t y , h o s t i l i t y Secur i ty Since marriage Determination that Eva w i l l be success f u l Mother Daughter Eva ' s ear ly i l l n e s s and h o s p i t a l i z a t i o n s plus her i n s e c u r i t y , e tc . C h i l d ' s l i f e Mother-image 2 years Overconcern, over-indulgence, i n c o n -s i s tent handling Mother Daughter E v a ' s v i o l e n t behaviour at 2 1/2 years of age plus her i n s e c u r i t y , e t c . Mother-image Few mos. Took Eva to Gordon House play group followed by a p p l i -c a t i o n to C l i n i c (1952) Mother Daughter E v a ' s poor school report Achievement, success Gradually i n t e n s i -fy ing over 5-year period A p p l i c a t i o n to C l i n i c ( I960) Mother Daughter Schedule E^ - Eva E. Age 11 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recip-r o c a l Role Mother's emotional i n -s t a b i l i t y , inconsistent handling, overindulgence Security Since b i r t h Insecurity, h o s t i l i t y , demanding behaviour Daughter Mother E a r l v i l l n e s s e s r Plus her i n s e c u r i t y Security 2 years Fearfulness, h o s t i l -i t y Daughter Mother Grandmother's strictness and harshness Security ? Fearfulness, h o s t i l -i t y Daughter Mother Father's i n a b i l i t y to set l i m i t s and give em-ot i o n a l support and mother's inconsistency Femininity 7-8 years Confusion regarding her i d e n t i f i c a t i o n — wears jeans, plays with boys, tomboyish behaviour Daughter Mother Demands of teachers plus her mother's expecta-tions Plus Eva's insec-u r i t y Achievement Self-esteen , 5 years i Underachieving i n school, cannot con-centrate Student Teacher Parents' h o s p i t a l i z a -t i o n (esp. father's) plus her in s e c u r i t y Security Past few months Regression, deter-i o r a t i o n i n academic work Student Teacher ] T H E . E" F A M I L Y h i ? . ^ C o t ^ \ N \ U N I T Y S T O D £ M \ N ot X m f a \ r e i - O M o l e t a t e l j j l r a f a w e i - © Not. e^vforttmfy'Ro'U ® Not Kuoum — © RG-. tr. re^f/o^N \ r\Nce \K M AT O R SOCIM* 'ROL^. 85 Assessment Case V Eva E . , an e leven-year-o ld g i r l , i s funct ioning at a moderately impaired l e v e l i n her r o l e s as daughter and peer, and at an extensively impaired l e v e l i n her r o l e as student. Her ear ly reac t ion to s tress was rebe l l i ousnes s , but more recent ly she has become discouraged and apathetic and has expressed the des ire to escape from her present environment. This r e a c t i o n has p a r t i c u l a r l y affected her student r o l e . Nothing i s known about her s i b l i n g r e l a t i o n s h i p s , although the general ized h o s t i l i t y with which she has responded to s t r e s s , i n the past , has poss ib ly impaired her performance i n t h i s area. The major sources of s tress have been her i l l n e s s e s i n the f i r s t two years of her l i f e which necess i tated frequent h o s p i t a l i z a -t i o n and separat ion from her mother and her mother's i n c o n s i s t -ency, occasioned by her own emotional problems, her husband's f a i l u r e to provide f o r her phys ica l and emotional needs, and E v a ' s i l l n e s s e s . Eva appears to be p a r t i c u l a r l y r e s e n t f u l towards her mother ( p a r t i c u l a r l y because of her assumption of the husband's func t ion of d i s c i p l i n a r i a n ) and thus i s experiencing some d i f f i c u l t y i d e n t i f y i n g with her . The most modif iable fac tor i n the fami ly s i t u a t i o n would appear to be Eva ' s r eac t ion to s t re s s . Both parents , however, may be 86 helped strengthen t h e i r performance i n the parental r o l e s through casework serv ices . I t i s u n l i k e l y that Mr. E . w i l l be able to meet h i s wi fe ' s requirements f o r success or to assume the r o l e of dominant partner even i f Mrs. E . could permit t h i s . L i t t l e improvement may be expected i n t h e i r performance of other r o l e s . I t would appear Eva could benef i t most from i n d i v i d u a l casework services d irec ted to strengthening her ego funct ioning and feminine i d e n t i f i c a t i o n . 87 CASE VI - FRANK F . Parents Mr. F . Mrs. F . C h i l d r e n Frank Louise Age 52 »+6 Occupation Profess ional Housewife 11 9 Student, Grade VII Student, Grade V Referred by: Mother, i n 1953> at the recommendation of the fami ly doctor because of eneurs i s , masturbation and antagonizing behaviour; and again i n 1955 because of Frank' s poor grade I r e p o r t , and again i n i960 because of h i s poor school per -formance. She i s a l so concerned about Louise ' s phobias. Presenting Problems: Mother fears Frank might lose c o n t r o l of himself and hurt someone. Cqse Nummarya Although Mr. F . has profes s iona l t r a i n i n g , he has been unable to give h i s fami ly much f i n a n c i a l s e c u r i t y . He has moved frequent ly from job to job , which has meant many changes of residence f o r the fami ly and periods of l i t t l e or no income. He i s described by the worker as impatient and explos ive . He v o i c -ed c r i t i c i s m of h i s w i fe ' s incons i s tency , and indulgence with 88 the c h i l d r e n . He sa id he i s unable to make f r i ends and i s not in teres ted i n community a f f a i r s . Both parents come from homes they describe as "unhappy.1 " According to Mrs. F . , her f a t h e r , who was b r u t a l and harsh , died when she was e leven. Her mother then operated a laundry where the c h i l d r e n worked long hours. She beat the boys with her f i s t s to e l i c i t obedience, and at times lapsed i n t o mental i l l n e s s and threatened s u i c i d e . Mrs . F . stayed out of trouble by conforming. She s t i l l f inds i t d i f f i c u l t to assert h e r s e l f , and gives i n to the c h i l d r e n to prevent q u a r r e l i n g . She has had rheumatism since she was fourteen and other I l l n e s s e s . She f ee l s i l l and t i r e d and f inds i t hard to cope with the c h i l d r e n and the house-work. Although Mrs. F . ' s mother i s now remarr ied , Mrs. F . and her husband have stayed with her occas iona l ly when Mr. F . has been away on a job or unemployed, and she i s a frequent v i s i t o r i n the F . home. According to Mrs. F . , the grandmother prefers Louise to Frank, and has been harsh with the boy. Mr. and Mrs. F . were staying with the grandmother when Frank was born. His mother r e c a l l e d that he was always a " d i f f i c u l t baby" with eating and sleeping problems, c o l i c , and frequent co lds . He was h o s p i t a l i z e d at four months to f i n d a s a t i s f a c t o r y formula. The fami ly moved several t imes, re turning to the grandmother's household when he was about two, because Mrs. F . was i l l and Mr. F . away. The grandmother t o i l e t - t r a i n e d Frank. Fol lowing 89 Louise ' s b i r t h , during t h i s per iod , Frank s tarted to wet h i s bed again , and had severe temper tantrums when he would hold h i s breath u n t i l he l o s t consciousness, and s tarted masturbating. In 1953, Frank was brought to the C l i n i c by h i s mother at the recommendation of her doctor . The presenting problems were eneureses, masturbation and antagonism. The C l i n i c defined three problems: 1. The frequent presence i n the home of the maternal grand-mother who re jec ted Frank i n favour of h i s s i s t e r Louise , Grandmother punished the boy and became very angry when she found him masturbating. 2. Mother's i n a b i l i t y to break the hosti le-dependent t i e to her own mother. 3. Unsat i s fac tory m a r i t a l r e l a t i o n s h i p , i n which both parents repress h o s t i l e f e e l i n g s , are unable to achieve a s a t i s f a c t o r y sexual adjustment, are unable to give the c h i l d r e n the warmth and secur i ty they need, have c o n f l i c t s about d i s c i p l i n i n g c h i l d r e n . Treatment at the C l i n i c continued through 195^  f o r parents and c h i l d . In 1955, Mrs. F . again contacted the C l i n i c because Frank' s grade I report noted h i s d e t e r i o r a t i o n i n work and behaviour. The teacher reported to the C l i n i c that Frank displayed i n c r e a s -ing masturbation, r e s t l e s s and s i l l y behaviour, resentment 90 towards other c h i l d r e n , wett ing , uncooperativeness, and d i d anything to get the teacher's attention* In h i s work, he was slow and messy, had d i f f i c u l t y p r i n t i n g and was regress ing i n h i s reading . Mrs. F . noted that at home Frank was d e f i a n t , swearing, masturbating, complaining of pains and s ickness , i n c r e a s i n g l y e n e u r i t i c , d isplayed temper tantrums, was depend-ent on h i s mother and hated going to school . Mrs. F . was most concerned about the school ' s c r i t i c i s m of Frank. The case was c losed again i n 1957 when general improvement was noted. In I960, the t h i r d a p p l i c a t i o n was made. Louise was a l so showing signs of emotional disturbance and treatment i s being provided f o r Frank, Lou i se , and both parents . SCHEDULE F 1 , F 2 , The F. Family Schedule F , - Mr. F . Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro -c a l Role Poor parental r e l a t i o n -sh ips , unhappy home l i f e Secur i ty , self-esteem Since childhood Fee l ings of inade-quacy, h o s t i l i t y , dependency Threatens a l l r o l e s Demands of employers Plus h i s inadeauacy f ee l ings Self-esteem Since adulthood Frequently leaves job Employee Employer Wife ' s dependency on her mother Plus h i s f ee l ings of inadequacy, dependency and h o s t i l i t y Self-esteem Since marriage Fee l s neglected and r e j e c t e d , "she does not value h i s opinions^" h o s t i l i t y , duodenal, u lcers Husband Wife Wife ' s object ions to h i s d i s c i p l i n a r y measures plus h i s i n s e c u r i t y , etc. Self-esteem, h i s pos i t i on of authori ty 10 years ? H o s t i l i t y because "she undermines h i s a u t h o r i t y , " "protects when,he punishes," f r u s t r a -t i o n , temper out-bursts Husband Wife Frank's behaviour Plus h i s i n s e c u r i t y Authori ty 7-8 years Resentment towards c h i l d Father Son Mr. F . ' s f ee l ings of i n -s e c u r i t y , h o s t i l i t y , m a r i t a l c o n f l i c t , job and residence changes Self-esteem ? Withdrawal from s o c i a l r e l a t i o n -ships ( i n a b i l i t y to make f r i e n d s , l a c k of i n t e r e s t i n community a c t i v i t i e s and organizat ions) Member of Commun-i t y Commun-i t y • - *• Schedule F 0 - Mrs. F. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-cal Role Parents 1 brutality, father's early death, mother's mental illness Life security Since childhood Conforming behaviour, h o s t i l i t y , g u i l t , feelings of inade-quacy, fear of assert-ing herself, hostile dependency on mother, psychosomatic illnesses Threatens a l l roles Husband's ina b i l i t y to provide physical and emotional suDOort, olus her feelings of inade-quacy, etc. Security • • Since marriage Returned with family to l i v e with mother at frequent i n t e r v a l s — additional i l l n e s s , migraine headaches, ho s t i l i t y , depression, insecurity Wife Mother Husband Son Frank's behaviour (pre-school) eneureses, masturbation, temper tantrums, olus her feelings of inadequacy Security, mother-image 2 years Application to Clinic (1953) Mother Son Frank's poor school report in Grade I plus her feelings of inade-quacy, etc. Family ego 6 mos. Application to Cl i n i c (1955) Mother Son Frank's behaviour and her fear of losing con-t o l , Louise's phobias olus her feelings of i n -adequacy Authority, self-esteen family ego ? Application to C l i n i c ( I 9 6 0 ) Mother Son Schedule F^ - Frank F . Age 11 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role 1 Mother's anxiety , de-pres s ion , i l l n e s s Securi ty Since b i r t h Anxie ty , ear ly eating problems, s leeping problems, overt depend-ency Son Mother Grandmother's harsh-ness during ear ly years , e s p e c i a l l y i n t o i l e t t r a i n i n g S e l f -esteem, independ-ence Since b i r t h Anxiety , h o s t i l i t y , g u i l t Son Mother Loui se ' s b i r t h , plus h i s i n s e c u r i t y , anxiety Place i n family 9 years Anxie ty , bedwetting, masturbation, temper tantrums Son Mother F a t h e r ' s resentment, h o s t i l i t y , plus h i s i n s e c u r i t y , anxiety, e t c . Masculine i d e n t i f i -dat ion 7-8 years Confusion re i d e n t i f i -cation-conforming , i n h i b i t e d , excess ive ly c o n t r o l l e d behaviour Son Father Grandmother's pre-ference f o r Louise plus h i s i n s e c u r i t y , h o s t i l i t y S e l f -esteem 9 years H o s t i l i t y towards Louise as w e l l as grandparents (h i t s Louise with f i s t s ) S i b l i n g S i b l i n g Demands of teacher plus h i s i n s e c u r i t y S e l f -esteem 6 years Underachieving i n school Student Teacher His i n s e c u r i t y , etc . S e l f -esteem, independ-ence 7-8 years Bosses other c h i l d r e n , argues, f i g h t s Peer Peers <o T H E F F A M I L Y Me. FC 1^ — / \ ( ) \ ; k y c^orvxNtOwvTy N o t I m^aiYel - O H o i e r a t e l ^ X r n f d a r c l - ~ Severel^  Xro^aurel -Hot' 'ftrf omuTigj l^ole ® Not: KXIOUAW - © T E e f o C T A A i ^ c ^ IN T A A T O G L ^ o c \ f \ L ^ O L P ^ ^ . 95 Assessment Case VI Frank F., an eleven-year-old boy has shown impairment since b i r t h i n h i s ro l e of son (he was a d i f f i c u l t , nervous baby) and subsequently extensive impairment i n h i s roles of s i b l i n g and peer, and moderate impairment i n h i s ro l e of student. He has reacted to the stresses imposed on him by fearing and r e s i s t i n g the demands of growth, as evidenced by h i s bed-wetting, smearing, masturbating, over-dependency on h i s mother, and by expressing much jealousy and h o s t i l i t y towards h i s younger s i s t e r . His e a r l i e r symptoms of disturbance have been f a i r l y well repressed, and now he i s overly controlled and i n -h i b i t e d , but s t i l l dependent on h i s mother. His major source of stress has been the f a i l u r e of both parents to perform adequately i n t h e i r parental r o l e s , a condition which has been exacerbated by a poor marital r e l a t i o n s h i p , c o n f l i c t over authority, and Mrs. F.'s hostile-dependent r e l a t i o n s h i p with her own mother. The b i r t h of h i s s i s t e r , Louise, coming at the c r u c i a l time when he was being t o i l e t -trained by h i s grandmother who was r e j e c t i n g and harsh, was another major source of stress. The grandmother's continued r e j e c t i o n of the boy and her obvious preference f o r Louise, have added greatly to the stress. The father's impatient, resent-f u l attitude towards Frank has made masculine i d e n t i f i c a t i o n even more d i f f i c u l t . In appearance he i s overweight and s l i g h t l y feminine. 96 The major area of i n t e r v e n t i o n poss ib ly should be i n the area of the source of s t r e s s , the ro l e impairment of Mr. and Mrs. F - . , with the goal of improving t h e i r m a r i t a l r e l a t i o n s h i p and strengthening t h e i r performance i n t h e i r parental r o l e s . Frank might a l so benef i t from casework services d i r e c t e d to strengthening h i s ego-functioning and h i s masculine i d e n t i f i -c a t i o n . 97 CASE VII - GORDON G. Parents Ag_e Occupation Mr. G. (step father) ? Professional (Government service) Mrs. G. ? Housewife Mr. A. - natural father (deceased) Logger Children Joe 19 ? Jim 17 Student, Grade ? Gordon 15 Student, Grade VIII (repeating) Patsy Ik Student, Grade ? Referred by: Mother, because Gordon stole money from newspaper route funds. Men from the newspaper company have been c a l l i n g at the house, causing the parents much embarrassment. Presenting Problems: Mrs. G. told the worker that Gordon i s unreliable, and has been stealing and l y i n g . Case Summary: Mr. and Mrs. G. with the children l i v e i n a large, comfortable home i n a good neighborhood. Mrs. G. has high housekeeping standards. The family has r e l a t i v e l y high status because of Mr. G.1s position and they are f i n a n c i a l l y comfortable. Mr. and Mrs. G. were married i n 1950, and Mr. G. has since adopted a l l the children. According to Mrs. G. he leaves the major 98 r e s p o n s i b i l i t i e s and decisions to Mrs. G. which she resents. Mrs. G. t o l d the worker that her f i r s t marriage was an extreme-l y unhappy one. She had trained as a nurse, primarily to escape from home and a t y r a n n i c a l father. She could not become i n -volved e a s i l y with single men, but instead went out with married men and formed an unhappy homosexual r e l a t i o n s h i p . She extricated herself from t h i s s i t u a t i o n by marrying Mr. A. They l i v e d i n logging camps and drank heavily. Then they moved to a more s e t t l e d area, where she returned to her occupation and found d i f f e r e n t f r i e n d s . She became more d i s s a t i s f i e d with her husband, seeing him as <. crude, unkempt, of low status, keeping poor company. She was c r i t i c a l and r e s e n t f u l . Gordon was born about t h i s time. Mrs. G. said she did not want him either before or a f t e r h i s b i r t h . While she was i n h o s p i t a l , her husband had an a f f a i r with the g i r l she had hired to care f o r Joe and Jim, and Mrs. G. was so upset she thought of poisoning the g i r l . She said she was not "normal" during t h i s period, and she added that the extra-marital a f f a i r s were most humiliat-ing to her. Gordon was born with an extra toe on each foot and an extra f i n g e r on one hand, and t h i s abnormality h i s mother found p a r t i c u l a r l y repulsive. She never held or cuddled him, and slapped him when he c r i e d . She said he wanted to be loved and would hang on to her neck, but she pushed him away. Patsy was born when Gordon was only fourteen months old. 99 According to Mrs, G. she preferred the g i r l to the boys and always favoured her . She was working during t h i s period as was her husband, but they worked opposite s h i f t s . When he was away on a job , she went out with the iceman to punish her husband and overcome her boredom. Short ly a f t er Patsy's b i r t h , Mr, A . was k i l l e d i n an automobile accident while on a dr inking party with another woman. Mrs . G. married her present husband about ten years ago. She t o l d the worker he nags at the boys and he and Joe, the o ldest boy, quarre l f requent ly . In 195*+, Joe then 13, was brought to the C l i n i c , by Mrs. G. He had been s tea l ing money from h i s mother and guests at the home and b u l l y i n g other c h i l d r e n . He tested "high on the moron range of general in te l l igence^ •' In 1955, J im, then 12, a huge obese boy, who whispered and c r i e d , was assessed as very withdrawn, funct ioning i n the "defective range of general i n t e l l i g e n c e . " Two years ago, Gordon had been caught forg ing small cheques at the drug store and s lashing car t i r e s , but i t was the embarrassment caused by the thef t of newspaper funds which brought Mrs. G. to the C l i n i c . At the C l i n i c , the psychologist reported that Gordon i s funct ioning i n the "borderline range of general i n t e l l i g e n c e , " but t h i s r a t i n g would seem to be minimal. In the psychometric tes ts he showed confusion about h i s sexual i d e n t i t y . He 100 expressed considerable discouragement about h i s rel a t i o n s h i p s with h i s parents, h i s schooling, and h i s future. SCHEDULE G x, G 2, G The G. Family Schedule G, - Mr. G. (step fa ther ) Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ip -r o c a l Role ? ? ? Passivenes s, withdrawal, leaves major re spons i -b i l i t i e s to wife Husband Wife Gordon's d i s t u r b -ed behaviour and poor scho las t i c achievements Family ego, reputa-t i o n 10 years (since marriage) Nagging and b e l i t t l i n g Gordon Father Son Gordon's thef t of newspaper money Reputa-t i o n A few days Extreme embarrassment, attended C l i n i c Father Son Schedule G~ - Mrs. G. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-l c a l Role Unhappy home environ-ment, d i c t a t o r i a l father (unresolved oedipal c o n f l i c t ) Self-esteem, femininity Since childhood H o s t i l i t y to males, homosexual r e l a t i o n -ship, marriage to man of l e s s status, edu-cation Wife Husband C u l t u r a l c o n f l i c t , desire to be with people of her own social status and c u l t u r a l group following t h e i r move to community from logging camps Plus her h o s t i l i t y S o cial status, s e l f -esteem 1-2 years ? H o s t i l i t y to Mr. A., resentment, nagg-ing Wife Husband Mr. A.'s extra-marital a f f a i r s Plus her h o s t i l i t y Self-esteem 2-3 years ? H o s t i l i t y , depression, revenge—went out with iceman Wife Husband Mr. G.'s p a s s i v i t y Security 10 years H o s t i l i t y to Mr. G. Wife Husband Gordon's theft of newspaper money Security, s o c i a l status Few days Application to C l i n i c Mother Son M a r i t a l c o n f l i c t , her g u i l t , h o s t i l i t y , boys" behaviour Self-esteem ? Withdrawal from social r e l a t i o n s h i p s (she does not want to bother with anyone) Comm-unity Member Community . — — . . - . Schedule G^ - Gordon G. Age 15 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role Mother's emotional i n s t a b i l i t y , r e j e c -t i o n , r evu l s ion towards h i s deformity L i f e s ecur i ty , self-esteem Since b i r t h Fee l ings of i n s e c u r i t y , f e a r , inadequacy, despair Son Mother Patsy's b i r t h when he was Ik mos. o ld His place i n family ? Intens i f i ed these f ee l ings Son Mother F a t h e r ' s death Secur i ty , male i d e n t i f i -cat ion Ik years Anxiety , confused i d e n t i f i c a t i o n .. Son Mother Mother's preference f o r Patsy, s tep-f a t h e r ' s b e l i t t l i n g a t t i tude Dlus h i s anxiety , i n s e c u r i t y , e t c . Self-esteem l*f years 10 years Hopelessness, sees being female more ad-vantageous than male, a d d i t i o n a l confusion re i d e n t i f i c a t i o n , l y i n g , s t ea l ing Son Employer Mother Employee C A S E 7. T H E . cS-. F A M I L / <=>\©MHG-Kl c>t X-m-oav ce3L — O MocWteij XmfavreA- <Q) Severely Xiwyaxrel —@ Not Kttouivv — © FlG-.T- -pCRFoP -^AKCe UM WKCSO^. S O C I A L ' R O L E ^ . 105 Assessment? Case ni Gordon G . , a f i f t e e n - y e a r - o l d boy has responded to the s tress he has experienced by withdrawal and discouragement. He i s despair ing of gaining love and recogni t ion from h i s parents , of passing i n school , and of achieving h i s des i re of becoming a mechanic. He i s immature, general ly confused regarding h i s sexual i d e n t i t y , and funct ioning under h i s I n t e l l e c t u a l poten-t i a l , which would seem to be below average. His general despa ir , coupled with h i s low i n t e l l e c t u a l a b i l i t y , has re su l t ed i n moderately Impaired funct ioning i n h i s r o l e of son, and extensively impaired funct ioning i n h i s r o l e s of peer and student. Nothing i s known of h i s s i b l i n g r e l a t i o n s h i p s . The major source of s tress has been the severe r e j e c t i o n by h i s mother from the time of h i s b i r t h . She d i d not want t h i s c h i l d , was ser ious ly d is turbed about her m a r i t a l s i t u a t i o n , and r e p u l s -ed by Gordon's deformity (extra f ingers and toes which have s ince been removed). The b i r t h of a younger s i s t e r when he was fourteen months of age, and h i s mother's overt preference f o r her daughter, added to the s t res s . His f a t h e r ' s death meant the l o s s of a male image and an unresolved oedipal c o n f l i c t , wi th consequent confusion around h i s sexual i d e n t i f i c a t i o n . Although Mrs . G. remarried when Gordon was f i v e or s i x , Mr. G. has been unable to give the boy much emotional support. 106 As the stress imposed on t h i s boy has been severe and has endured since h i s b i r t h , i t i s u n l i k e l y vast improvement can be expected i n h i s s o c i a l functioning. However, he could possibly benefit from casework services to bolster h i s f e e l i n g s of s e l f -worth and strengthen h i s masculine i d e n t i f i c a t i o n . Mrs. G., too, has been subject to severe stress over a long period but has achieved some improvement i n her s o c i a l function-ing. This would indicate she could benefit from casework services, directed p a r t i c u l a r l y to strengthening her performance i n the r o l e s of wife and mother. 107 CASE V I I I - HOWARD H . Parents (Divorced 1959) Mr. H. Mrs. H . C h i l d r e n (from Mr. H . 's f i r s t marriage) B i l l Betty (of Mr. and Mrs. H . ) Howard Helen 3^ 35 Occupation Labourer Restaurant Worker 20 18 9 8 Armed Services High School S p e c i a l Class Student Student, grade ? Referred by: Mother, f i r s t i n 1958 because of Howard's f a i l u r e i n grade I , and again i n i960 because land lord had threatened them with e v i c t i o n because of Howard's temper tantrums. Presenting Problems: Mother i s concerned about Howard's temper tantrums and f inds him unmanageable. She a lso complained that he has been s tea l ing things around the house. Case Summary: Mr. and Mrs. H . separated i n 1959 and are now d ivorced . Mrs. H . with B e t t y , Howard and Helen , have moved i n t o a small s u i t e . Mrs. H . i s present ly working twelve hours per day and has had a 108 series of housekeepers l i v i n g i n . Shortly a f t e r a p p l i c a t i o n , Mrs. H. sent Betty back to her natural mother, because she and Howard fought constantly. According to Mrs. H., t h e i r ten years of married l i f e were marred with arguments and f i g h t s . They seldom went out together or entertained. She said that her husband b e l i t t l e d her i n company, was harsh with the children, and drank too much. He had also been i n a s p e c i a l class at school. He worked as a labourer and was unable to provide well f o r the family. Mrs. H. bought the house which she rents, with her money when they were married and also bought the car. Howard was born the year following t h e i r marriage. The pregnancy was d i f f i c u l t . Mrs. H. developed kidney i n f e c t i o n and had to stay off her f e e t . She said Mr. H. was "miserable" to her, and did not seem to want the baby. The mother described Howard as an "unhappy baby from b i r t h . " He had constant diarrhea, and banged h i s head ste a d i l y against h i s c r i b . Mr. H. accused her of giving too much a f f e c t i o n to Howard and neglecting h i s older children. In 1958 Mrs. H., who had previously been to the C l i n i c with B i l l and Betty, contacted the C l i n i c to ask f o r help with Howard because he had f a i l e d i n Grade I. By the time of the second application the parents were divorced but the arrangement had been made that Mr. H. would see the children. He has, according to Mrs. H., shown more i n t e r e s t 109 i n Howard recently. Mr. H. (described by the worker as an immature, dependent, person), thinks that Howard i s too much l i k e h i s mother. Mrs. H. (described by the worker as insecure, having had l i t t l e a f f e c t i o n and too high standards) thinks that Howard i s l i k e h i s father, with h i s father's red h a i r , temper and outlook on l i f e . Although he pleases her by running errands, and helping her with housework, she i s most displeased with h i s c l i n g i n g , babyish manner. She complains Howard i s sp o i l i n g her l i f e . At the C l i n i c , the psychologist reported that Howard tested i n the "borderline range of general i n t e l l i g e n c e . " Psychometric te s t s indicated he i s immature, insecure and emotionally deprived. He seems f e a r f u l of lo s i n g a l l sources of s a t i s f a c t i o n . SCHEDULE H x, Hg, H The H. Family Schedule H, - Mr. H. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-c a l Role ? ? ? Dependency, f e e l i n g s of inadequacy and h o s t i l i t y Husband Wife Wife's superior i n t e l l e c t u a l a b i l -i t y , f i n a n c i a l s i t u a t i o n and her i n a b i l i t y to meet hi s dependency needs Self-esteem Since marriage B e l i t t l i n g h i s wife, drinking, harshness, paranoidal tendencies Husband Wife Howard's unwelcome b i r t h His place i n wife's affections Since Howard's b i r t h Ambivalence toward c h i l d , denial of Howard's needs, (he di d not l e t her (mother) give the children the love they needed) • Father Son Schedule H 0 - Mrs. H . Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro-c a l Role E a r l y emotional depr iva-t i o n r Secur i ty , self-esteem Since b i r t h ? Insecur i ty , inadequacy, marriage to man with l e ss education, l e s s money, poor employment prospects (she paid for home and car ) Threatens a l l r o l e s Husband's i n a b i l i t y to meet her phys ica l and emotional needs plus her i n s e c u r i t y , e tc . Secur i ty , emotional s t a b i l i t y , marriage Since marriage H o s t i l i t y , psychosoma-t i c d i s o r d e r s , ( i n f e c -t i o n s , headaches, sinus trouble) Wife Hus-band Husband's d r i n k i n g , harshness, plus her i n s e c u r i t y , h o s t i l i t y Self-esteem Since marriage but i n t e n -s i f y i n g Divorce - 1959 Wife Hus-band M a r i t a l c o n f l i c t , husband's r e j e c t i o n of c h i l d plus her i n s e c u r i t y ? Since Howard•s b i r t h Ambivalent f e e l ings toward Howard Mother Son Howard's f a i l u r e i n Grade I plus her i n -s e c u r i t y C h i l d ' s fu ture , mother-imag* 6-7 mos. A p p l i c a t i o n to C l i n i c (1958) Mother Son Landlord's threats to remove them because of Howard's temper tantrums Securi ty A few days ? A p p l i c a t i o n to C l i n i c ( I 960) Mother Son Husband b e l i t t l e d her i n f ront of others plus her i n s e c u r i t y , e tc . Self-esteem Since marriage Withdrawal from s o c i a l r e l a t i o n s h i p s (they r a r e l y went out—never entertained—she has no fr iends) Community member Comm-unity Schedule - Howard H. Age 9 Years Source of Stress Value Threaten-ed Duration of Stress Response to Stress Major Role Impair-ed Recip-r o c a l Role Mother's anxiety, i l l n e s s , ambivalent f e e l i n g towards him L i f e security Since b i r t h Anxiety, fearfulness, constant diarrhea, head banging, "un-happy c h i l d frpm b i r t h " Son Mother Parents 1 continual arguing and f i g h t i n g — a n d f i n a l separation l a s t year plus h i s anxiety, fearfulness Security Since b i r t h • Fearfulness, h o s t i l -i t y , depression, babyishness, depend-ency, temper tantrums, abdominal pains, headaches Son Mother Demands of teacher plus Howard's "borderline" mentality plus h i s insec-u r i t y , fearfulness Self-esteen 2 years F a i l u r e i n school l a s t year, underachieving i n special class t h i s year Student Teachei Fearfulness, anxiety, i n -f e r i o r i t y , depression S e l f -esteem Since b i r t h but i n t e n s i -fying Plays best with only one c h i l d at a time, cannot pa r t i c i p a t e i n group a c t i v i t i e s Peer Peer 8 T H E H . F A M I L Y STOOErlT"-M o t I w ^ a i f e l — O Severely Xn\vaire3.~ Not^r^ovmm^QU® Mot Kwouw — © F i c i - . S ? E E ^ o ^ K \ M ^ C t £ I Kl 1AA<TO\CL S o C \ A \ _ ^ O L E ^ . Assessment Case VIII Howard H., a nine-year-old boy, i s performing at an extensively impaired level i n his role of student, and at a moderately im-paired level i n his roles of son, sibling and peer. His reaction to stress has been to attempt to maintain his infantile relation-ship with his mother, as evidenced by his over-dependency, clinging, babyish behaviour, and h o s t i l i t y which erupts i n temper tantrums. He reacts with abdominal pains and headaches when his mother becomes impatient with him and their relationship i s threatened. His sources of stress have been his mother's ambivalent feelings towards him from birth, a result of her emotional disturbance and serious marital conflict5 the birth of his sister when he was one-year-old; his father's i n a b i l i t y to give him affection and emotional support; the parents' separation and divorce last year; and his mother's present long working hours which deprives him of her care and attention. His fearfulness and dependency, together with his limited intellectual capacity, have resulted i n his failure i n school last year and underachievement i n special class this year. The most modifiable factor would seem to be Mrs. H.*s performance in the role of mother. But because she w i l l also have the responsibility of supporting the family, an additional source of 115 stress f o r her, and w i l l have l i t t l e time to spend with Howard, much improvement cannot be expected i n t h i s area. As the other major stress f a c t o r , h i s parents' separation, cannot be modified, Howard might be helped, through casework service, to contend more e f f e c t i v e l y with the stress. 116 CASE IX - IKE I . Parents Age Occupation Mr. I , 30 Carpenter Mrs. I . 27 Housewife C h i l d r e n S h i r l e y 8 Student-grade I I I Ike 6 Student-grade I Rose (born one month a f ter a p p l i c a t i o n to C l i n i c ) Referred by: Mother, at the recommendation of the fami ly doctor to whom she had gone because the school teacher t o l d her Ike should be seen by a p s y c h i a t r i s t . Presenting Problems: Mrs. I . t o l d worker Ike i s going poorly i n school . He i s e p i l e p t i c and s tu t ters and she f inds him hard to manage. Case Summary: This young couple l i v e i n an unfinished house i n the out sk i r t s of the c i t y . Mr. I . works s t ead i ly and i s f i n i s h i n g the house as he can a f ford to get m a t e r i a l . They were married when she was seventeen and he, twenty. According to Mrs. I . , her ear ly l i f e was most unsat i s fac tory . Her mother was an a l c o h o l i c , her father a drug add ic t , and she and her 117 brother became wards of a c h i l d welfare agency while s t i l l very young. She was moved from fos ter home to fos ter home, so that she f e l t she d i d not belong anywhere. She was eventual ly placed i n a convent, but r e b e l l e d at the d i s c i p l i n e , and at s ix teen , was asked to leave . She had worked for a summer the previous year at the farm owned by Mr. I . ' s parents and she returned there at that time. She and Mr. I . were married the fo l lowing year . Both her parents are now dead, but p r i o r to her death, her mother had v i s i t e d i n the home. Mrs. I . sa id the grandmother could not to l era te Ike , because he was shy, but l i k e d S h i r l e y . Mrs. I . ' s brother , now a drug a d d i c t , who has been i n and out of j a i l , stays at the house f requent ly , but Mr. I . does not approve of t h i s . Recent ly , he arranged for h i s own brother , who i s working on a contract with him, to board at the home so there i s no longer room f o r Mrs. I . ' s brother . According to the school nurse, there i s a h i s t o r y of epi lepsy i n Mrs. I . ' s f a m i l y , but Ike showed no symptoms of t h i s d isorder i n h i s f i r s t few years . His mother has sa id he was a hea l thy , happy baby. When he was three , a bakery truck backed up on him while he was playing i n the s t ree t . Mrs. I . saw him and screamed. The truck stopped but not before the t i r e had scraped the h a i r of f one s ide of Ike's head. Although X-rays showed no permanent damage had been done, according to h i s mother, Ike s tar ted to s tu t ter about t h i s time and seemed more f e a r f u l . 118 When he was f i v e , he had h i s f i r s t major seizure. Since then he has had ten to twelve major seizures and a number of minor, b r i e f seizures. He i s now on medication. Both parents expressed much concern about Ike's seizures, and hesitate to d i s c i p l i n e him f o r fear of p r e c i p i t a t i n g them. Mrs. I. thinks that Ike i s retarded but does not know exactly where he does f i t i n . He i s hard to manage, hi s speech i s d i f f i c u l t to understand and he can't think f o r himself. He has temper tantrums but mother says these are not too hard on her, because now she does not i n s i s t on obedience. He used to bawl and throw himself on the f l o o r , but she "knocked that out of him." She describes him as a " l i t t l e brat." He gets in t o trouble with the neighbours, l i g h t s f i r e s , takes the neighbours' too l s and children's toys. She f e e l s he prefers h i s father to her. S h i r l e y , Ike's older s i s t e r , has always been expected to look a f t e r Ike. According to Mrs. I., she i s more aggressive and has never been any trouble to her parents, but she and Ike quarrel. Other children pick on Ike, c a l l i n g him a "dumbell" and "stupid" which hurts h i s f e e l i n g s . He usually plays with younger children. At the C l i n i c , Ike tested "high i n the borderline range of general i n t e l l i g e n c e " but h i s potential i s possibly i n the average range. The psychologist reported that he seemed confused, i n -secure, unhappy and unsure of h i s own i d e n t i f i c a t i o n . In the 119 t e s t , he gave evidence of angry f e e l i n g s towards others, h i s parents, s i s t e r , and school authorities and seems to f e e l a general lack of acceptance f o r himself from others. V SCHEDULE I x , I 2 , I The I. Family Schedule I, - Mr. I. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recip-rocal Role Ike's seizures Son's future and health 1 1/2 years Fearful of precipitat-ing seizures—lack of firmness with Ike. Father Son Ike's poor school performance Son's future family ego lf-5 mos. Involvement i n treat-ment at Clinic • Father Son Schedule I 0 - Mrs. I. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recip-rocal Role Early emotional depriva-tion, no consistent parent figures, lack of opportun-i t y to learn mother role Security, self-esteem Since birth Feelings of Inadequacy, insecurity, lack of confidence, dependency Threatens a l l roles Ike's seizures plus her lack of confidence Child's l i f e 1 1/2 years Fearfulness, g u i l t , inconsistent handl-ing, either "trims him up" or indulges him Mother Son Teacher's concern about Ike's poor progress, mis-behaviour and her sugges-tion Ike see a psychia-t r i s t , Plus mother's insecurity Mother-image ("They don't think I am a very capable mother") lf-5 mos. V i s i t to family doctor, application to Clinic . . . - . i , - i - - - _ - -Mother Son Schedule 1^  - Ike I , Age 6 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro -c a l Role Mother's i n s e c u r i t y , l a c k of confidence, inconsis tency Securi ty Since b i r t h Confusion, anxiety , h o s t i l i t y • Son Mother Truck accident Secur i ty - Fearfu lness , s tu t ter ing Son Mother E p i l e p t i c seizures L i f e 1 1/2 years A d d i t i o n a l f e a r f u l -ness Son Mother Mother's incons is tent handling because of her fear of seizures Secur i ty 1 1/2 years H o s t i l i t y , stubborness temper tantrums, f i r e s e t t i n g , s t ea l ing toys , Son Mother Grandmother's prefer -ence for S h i r l e y , S h i r l e y ' s aggressive-ness and e f for t s at domination Self-esteem, Independence, Place i n family 3-*t years H o s t i l i t y to S h i r l e y , q u a r r e l i n g , cry ing S i b l i n g S i b l i n g Teacher's demands olus Ike's f e a r f u l -ness , h o s t i l i t y Self-esteem 6 mos. Functioning below potent ia l , misbehaving Student Teacher C h i l d r e n ' s teasing plus Ike's fearfulness, h o s t i l i t y Self-esteem 6 mos. Hi t s other c h i l d r e n , won't cooperate i n group p l a y , plays with younger c h i l d r e n Peer - ~ - — Peers T H E I . F A M I L Y MR.. X . ct-WfAONrry 1 7 L t^CrE lKD Not i t t i ^ f r e c l - O Not"?ed^mmgj "Role ® Wot Kuo^tv - © F I G . <3 T G e - F o ^ w \ r \ v \ e e h A j o ^ ^OOAL - R o u e . ^ 12!+ Assessment Case IX Ike I., i s a six-year-old boy whose performance i s severely im-paired i n the student r o l e , extensively impaired i n the son and peer roles, and moderately impaired i n the s i b l i n g r o l e . His response to stress has been to c l i n g to h i s i n f a n t i l e r e l a t i o n -ship with h i s mother, as evidenced by h i s baby t a l k , over-depend-ency, temper tantrums, and by h i s way of taking what he wants when he wants i t . His st u t t e r i n g , and to some extent, h i s ep i l e p t i c seizures, may also be a reaction to stress. Although his i n t e l l e c t u a l p o t e n t i a l i s average, he i s functioning i n the borderline range. The major sources of stress seem to be h i s parents* inconsistent handling and h i s seizures. Shirley's aggressively dominant be-haviour, the incident of the truck backing up on him, and the other children's response to h i s general impairment (they c a l l him "stupid") have added to the stress. Casework services might be primarily directed at strengthening both parents' performance i n the parental r o l e s . Ike, too, may benefit from casework services. A warm, consistent r e l a t i o n s h i p would give him some of the emotional support and security necessary f o r an improvement i n h i s s o c i a l functioning. 1 2 5 CASE X - JEAN J. Parents Age Occupation Mr. J. ? Policeman Mrs. J. 3 8 Housewife Children Donna 1 0 Student-grade V Jean 8 Student-grade III Referred by: Mother*, at the recommendation of the family doctor, because Jean has been s o i l i n g every day for the past two months. This i s the second episode i n a year. Presenting Problems: Mrs. J . reported Jean has been s o i l i n g , wetting herself occasionally, and seems unhappy and pre-occupied. She i s slow i n school and i s continually bickering with her s i s t e r , Donna. Case Summary: The J. family l i v e i n a small house i n the C i t y . Mr. J. whom the worker described as quiet and steady, has been i n the police force f o r a considerable time and seems content with h i s job. Mrs. J . , who seemed to the worker to be anxious and r e s t r i c t i v e , was subsequently diagnosed at the C l i n i c as an "obsessive-compulsive type" of personality. In her childhood she was 126 p h y s i c a l l y and emotionally deprived. Her father was an alcoholic who abused h i s wife and children. Her mother was generally incapacitated with psychosomatic i l l n e s s e s . Mrs. J. has had asthma most of her l i f e . She l e f t school a f t e r f i n i s h i n g Grade VIII, and did housework. Mr. and Mrs. J. were married during the War, when Mrs. J. was twenty-one. A few days l a t e r , Mr. J. l e f t f o r overseas and was away f o r over two years. Their f i r s t c h i l d , Donna, was born seven years aft e r t h e i r marriage, and two years l a t e r , Jean was born. Just a f t e r Jean's b i r t h , Mr. J.'s father came to stay with the family. He was dying of cancer and Mrs. J. said she was repelled by h i s i l l n e s s and h i s appearance. The house was small, they were crowded together, and she d i d not want the childr e n to be near him. This experience was quite upsetting to her. Jean was a c o l i c k y baby f o r the f i r s t two or three months, and subsequently had various i l l n e s s e s — c o l d s , sore throat, i n -flammation of the bladder. Two years ago, both c h i l d r e n had t h e i r t o n s i l s and adenoids removed. Jean was quite i l l and upset. Her mother could not v i s i t her at the h o s p i t a l because she, too, was i l l . According to both parents, Donna i s outgoing, bright, feminine and the family favourite. Donna gets new clothes, but Jean gets clothes passed on from Donna and from a cousin. Jean i s quieter than Donna, boyish, slow i n school, untidy, prefers playing with boys and guns to doing housework and homework. Her father i s most concerned about her tomboyishness. 127 At the C l i n i c , the psychologist reported that Jean tested "high on the average range of general i n t e l l i g e n c e " but appears to have a higher p o t e n t i a l . She has a deep voice, boyish manner and walk. The psychologist noted that she seems generally immature, lacks controls, i s very h o s t i l e , p a r t i c u l -a r l y towards her mother, and i s moving towards masculine i d e n t i f i c a t i o n . She seems to crave acceptance from other children. SCHEDULE J 1 ? J 2 , J The J . Family Schedule J, - Mr. J. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-c a l Role ? ? ? C r i t i c i z e s wife's performance as mother, w i l l not support her d i s c i p -l i n a r y e f f o r t s Husband Wife Jean's boyish be-haviour, her prefer-ence f o r boys and guns to housework and schoolwork Daughter 1s femininity 3 ^ years Involvement i n treatment at C l i n i c Father Daughter Schedule J 0 - Mrs. J. Source of Stress Value Threaten-ed Duration of Stress Response to Stress Major j Recip-Role r o c a l Impaired Role Emotional and material deprivation i n childhood Security Since b i r t h Feelings of inadequacy, i n s e c u r i t y , h o s t i l i t y "obse ssive-c ompulsive" behaviour, asthsma Threatens a l l r o l e s Lack of emotional support from husband: h i s c r i t i c i s m of her per-formance as motherj h i s expectation that 'good mother' always remains with ch i l d r e n , his re-luctance to help her with housework, he didn't help her i n knowing how to deal with c h i l d r e n , his defence of c h i l d r e n when she sets l i m i t s Self-esteem, freedom, independ-ence, security, authority Since c h i l d -ren' s births H o s t i l i t y , additional lack of confidence i n h e r s e l f , fears c h i l d -ren w i l l l i k e father better than her because she has to d i s c i p l i n e them Wife j Hus-j band Father-in-law's v i s i t at time of Jean's b i r t h ? Additional anxiety, repulsed by h i s i l l -ness (cancer) Mother I Daugh-1 ter Jean's untidyness, i n a b i l -i t y to communicate, bicker-ing with Donna, slowness i n school Mother-image, family ego 5-6 years H o s t i l i t y to Jean Mother jpaugh-1 t e r Jean's s o i l i n g C l e a n l i -ness 2 mos. V i s i t to family doctor and a p p l i c a t i o n to C l i n i c Mother foaugh-1 ter Schedule J ^ - Jean J . Age 8 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ip-r o c a l Role Mother's anxiety and i n -secur i ty L i f e security. Since b i r t h Anxiety , i l l n e s s , c o l i c k y for f i r s t 2-3 mos., head-co lds , sore throat , i n -flammation of b ladder , h o s t i l i t y to mother, withdrawal Daughter Mother Parental c o n f l i c t re author i ty Secur i ty Since b i r t h A d d i t i o n a l anxie ty , h o s t i l i t y , rebe l l iousness Daughter Mother Unresolved oedipal c o n f l i c t Feminin-i t y U_5 years Boyish mannerisms, moving to masculine i d e n t i t y Daughter Mother Parents' preference for Donna and Donna's teas-ing and aggressiveness P lu s Jean's i n s e c u r i t y , h o s t i l i t y S e l f -esteem *4~5 years H o s t i l i t y to Donna, threatens to tear up her books, takes her money (and poss ib ly fur ther r e b e l l i o n against femin-i n i t y which parents p r i z e i n Donna) S i b l i n g S i b l i n g Demands of teacher p lus Jean's i n s e c u r i t y Achieve-ment, s e l f -esteem Poor academic performance, untidyness, daydreaming Student Teacher Insecur i ty , confusion re i d e n t i t y ? •+-5 years Plays with boys a few years older than h e r s e l f Peer Peers T H E . JT F A M I L Y / 1^ •— i S=>T~0 PE .NT. MoT X w A p a u e c l — O ^tensivJGl^XTnpan-e<i - @ SeweVv^XtTvoau'ecJ, - ® Not K T X O O O Y V . - ( ? ) 132 Assessment Case, % Jean J . , an eight-year-old g i r l , i s performing at the moderately impaired l e v e l i n the ro l e s of daughter, peer and student, and shows extensive impairment i n her r o l e as s i b l i n g . She has responded to stress by regressing to an e a r l i e r stage of matura-t i o n (anal from oedipal phase) and by moving towards masculine i d e n t i f i c a t i o n . She i s quiet, withdrawn, slow and untidy, has reverted to s o i l i n g , and i s acquiring some masculine t r a i t s , a deep voice, boyish manner and walk, and masculine i n t e r e s t s . The major source of stress which has affected t h i s c h i l d since b i r t h has been her mother's anxiety and i n s e c u r i t y , a r e s u l t of her own emotional problems and her husband's i n a b i l i t y to give her support i n her r o l e of mother. Another primary source of stress has been the overt preference of both parents f o r Donna, Jean's older s i s t e r . Jean's h o s t i l i t y f o r Donna would seem to have made her rebel against the c h a r a c t e r i s t i c s which the parents admire i n Donna. As Donna has become more feminine, neat and t i d y , h e l p f u l and outgoing, Jean has become more masculine, untidy, r e s i s t a n t and withdrawn.. As the major source of stress stems from the parents' inadequacy i n t h e i r roles of mother and father, t h i s might be one area of intervention. Both parents could benefit from casework services, although treatment f o r Mrs. A . because of her greater degree of impairment, may be r e l a t i v e l y long-term. 133 As the other source of stress i s the unsatisfactory s i b l i n g r e l a t i o n s h i p , casework services f o r Jean might help her establish her own sense of i d e n t i t y . 13-+ CASE XI - KEN K. Parents Mr. K. Mrs. K. C h i l d r e n May-Ken Peter Age 33 31 9 6 1/2 k Occupation Mil lworker (un-employed) Housewife Student, grade I I I Student, grade I Referred by: Presenting  Problems: Fa ther , at the recommendation of the fami ly doctor because of Ken's pers i s tent coughing, f o r which there i s no phys i ca l j u s t i f i c a t i o n . Father i s a f r a i d Ken has i n h e r i t e d mental i l l n e s s . He coughs p e r s i s t e n t l y , frequent ly wipes h i s hands on h i s f a c e , and i s doing poorly i n school . Case Summary: Mr. and Mrs. K. were married when he was twenty-two, she, twenty. He has not been r e g u l a r l y employed since t h e i r marriage. Mrs. K. has r e f e r r e d to him as "accident-prone" because of the many accidents he has had. Several years ago he suffered a back i n j u r y which has r e s t r i c t e d h i s employabi l i ty to some extent. Over the years the fami ly has p i l e d up many debts , a big worry f o r both parents . 135 There i s a h i s t o r y of mental i l l n e s s i n the family. Mr. K. 1s mother was admitted to the mental h o s p i t a l when he was nine years old, and i s s t i l l there. The diagnosis was "paranoid schizophrenia with s u i c i d a l tendencies." She had been i l l f o r some time p r i o r to her admission, and Mr. K. remembers t h i s period of h i s l i f e very v i v i d l y . He was referred to the C l i n i c when he was seventeen, because he was worried about becoming l i k e h i s mother. He did not return f o r treatment. Mrs. K.'s mother had also suffered from mental i l l n e s s . Mrs. K. and her father had a close affectionate r e l a t i o n s h i p . Mrs. K., l i k e her husband, had been referred to the C l i n i c when she was seventeen. At that time she l e f t school having become very disturbed by the death of her older brother of cancer. She had been nursing him f o r some time. Her brother and s i s t e r s went through University and she f e e l s quite i n f e r i o r to them because of her lack of education. She has since seen several p s y c h i a t r i s t s because of frequent depressions but has found l i t t l e r e l i e f . She was severely depressed at the time of Ken's b i r t h , and remained i n a depressed state f o r about a year afterwards. Two years ago, Mrs. K. took an overdose of sleeping p i l l s and was admitted to Crease C l i n i c f o r a few days. The parents f e e l that t h e i r neighbors have withdrawn from them since t h i s incident, and they, i n turn, have withdrawn from the neighbors. The chi l d r e n , too, are i s o l a t e d , and play by themselves. According to the parents, May the oldest c h i l d protects and mothers Ken. She takes him to h i s classroom and c a l l s f o r him 136 af ter school . She a lso bosses him around, and Ken teases her . Mrs. K. was re luc tant to come to the C l i n i c , but was persuaded by her husband. She bel ieves Ken's problems are unavoidable because he i s l i k e her . She complains that her husband does not give her enough a f f e c t i o n and wishes she had gone on to Univer-s i t y and a career instead of marrying. At the C l i n i c , the psychologist reported that Ken tested "low i n the average range of general i n t e l l i g e n c e , " but probably has higher p o t e n t i a l . In psychometric t e s t s he appeared f e a r f u l and immature with much repressed h o s t i l i t y he feared to express. There was evidence of a poor r e l a t i o n s h i p with e i ther parent, and concern about h i s r e l a t i o n s h i p s with other c h i l d r e n p a r t i c u l -a r l y h i s s i s t e r , May. SCHEDULE K x, Kgl K The K. Family Schedule K, - Mr. K. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recip-r o c a l Role E a r l y emotional depriva-t i o n and mother's i n s t i t u t i o n a l i z a t i o n Security, self-esteem Since childhood Feelings of inadequacy, fearfulness of close relationships Threatens a l l r o l e s Wife's demands for affeo-t i o n , emotional support Plus h i s fe e l i n g s of i n -adequacy Security Since marriage "He can't compete with her father, a f r a i d to give her too much affections-some-thing always happens to people he i s fond o f " — p a s s i v i t y (cannot argue with her, just walks away) Husband Wife Demands of employers plus h i s Insecurity Self-esteem Since adulthood Accident-proneness, frequent withdrawal from labor market Employee Employ-er Fear of Ken's i n h e r i t i n g mental i l l n e s s plus Mr. K.'s in s e c u r i t y , i n -adequacy Child's mental health, family ego 3-*+ years Application to C l i n i c Father Son His wife's mental i l l -ness and attempted sui c i d e , paranoidal tendencies plus, his i n -security Family r e -putation 2 years Withdrawal from contacts with friends and neighbors Commun-i t y Member Comm-unity Schedule K 0 - Mrs. K. Source of Stress Value Threaten-ed Duration of Stress Response to Stress Major Role Impaired Recip-rocal Role Her mother's mental i l l -ness, her very close affectionate relationship with father (unresolved oedipal co n f l i c t ) , brother's death Security Since early childhood Anxiety, "neurotic-depressive reaction" additional anxiety, l e f t school, feels inferior to siblings Threatens a l l roles Her husband's inabi l i t y to show affection plus her anxiety, depression Security, self-esteem Since marriage Hostility, resentment to Mr. K. (would pre-fer not to be married) symbiotic relation-ship with son (Kenneth) Wife Son Husband Mother Her fears of being re-jected by neighbors following her admission to Crease Clinic Suspiciousness, dis-trust, withdrawal from social contacts Commun-it y Member Commun-i t y Schedule K-> - Ken K, Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impair--fid Recip-rocal Role Mother's emotional dis-turbance, depression, her Inability to allow him emotional independence Security, self-esteem Since birth Fearfulness, anxiety, insecurity, repressed h o s t i l i t y , dependency, inhibited behaviour Son Mother Father's in a b i l i t y to give him affection, emotional Security, self-esteem support, concern father's over-(Continual coughing, face-wiping, daydream-ing, talking to him-self, occasional bed-wettmg) Son Father Sister's overprotection plus his insecurity, dependency Independ-ence, self-esteem Since birth Dependency and sub-mission to sister's domination, h o s t i l i t y (repressed) Sibling Sibling Family's isolation plus Ken's fearfulness, i n -security Security 2 years Does not play with other children, stays home after school Peer Peer Demands of teacher plus, Ken's fearfulness, i n -security, dependency Security, self-esteem Does not want to go to school, underachiev-ing, short attention span, restlessness, dependency on teacher Student Teacher T H E . K . F A M I L Y ;OMMON I T " / C & V A t A O N V T y m e m e e t ? . Hot I v n o a i ^ ^ - O SUferVxtUj T r a v e l . - 0 Hot ^v^ov-vt-vTi^'XolNfi-® t-VG-. n.. ' p e R P o R . ^ A ^ H C l ? IN r\A3*0K. SOCIAL ^OL.E:S\ l * t l Assessment Case XI Kenneth K., a six-year-old boy, i s performing at a moderately impaired l e v e l i n the r o l e of son, extensively impaired l e v e l i n the rol e s of s i b l i n g and student and severely impaired l e v e l i n the ro l e of peer. He has reacted to stress by attempting to maintain the i n f a n t i l e r e l a t i o n s h i p with h i s mother. He i s dependent, immature, f e a r f u l of new experiences, and imitates some of h i s mother|s nervous mannerisms, such as the face-wiping routine. His desire to remain a baby i s also evident i n h i s submission to h i s s i s t e r ' s e f f o r t s at mothering and i n h i s re l a t i o n s h i p with h i s teacher. The main sources of stress have been h i s mother's emotional disturbance (and p a r t i c u l a r l y her state of depression during h i s early years), which has seriously affected her performance i n a l l r o l e s . The father's anxiety and concern f o r the boy's mental health, along with h i s p a s s i v i t y and i n s e c u r i t y , has seriously impaired h i s r o l e performance. Neither parent has been able to give the boy much a f f e c t i o n and emotional support. The parents' reaction to t h e i r fear of r e j e c t i o n by t h e i r neighbors, has been another source of stress f o r Ken. Based on t h i s material, the major area of intervention might be i n the stress-producing area rather than i n the c h i l d ' s reaction to stress. The sources of stress may be modified by psychiatric treatment f o r Mrs. K. and casework services f o r Mr. K. The Day Centre f o r C h i l d r e n may provide a subst i tute peer group for Kenneth u n t i l the neighborhood r e l a t i o n s h i p s improve and he has gained more sense of s e c u r i t y . 1-+3 CASE XII - LANA L . Parents Mr. L . Mrs. L . ChUdren, Bob Betty Lana Referred, feys 9 8 6 Self-employed Housewife Student, Grade ? Student, Grade ? Presenting ^•.objeffls: Mrs. L . ' s worker at C h i l d r e n ' s C l i n i c because of the d i f f i c u l t y of separating Lana from her mother at interview times. Mrs. L . and Bob were already attending the C l i n i c . Mrs. L . wonders whether Lana w i l l be able to separate from her when she s tar t s school next September. Otherwise she bel ieves Lana i s the only healthy member of the f a m i l y . Case Summary» According to Mrs . L . , when she met her husband about ten years ago, he had separated from h i s wife and c h i l d r e n , and was drink-ing quite heav i ly and not working s t e a d i l y . Af ter she went to l i v e with him they worked together to b u i l d up h i s business . I t was a hard s trugg le , f o r they had l i t t l e money. They were just becoming es tabl i shed when the present recess ion commenced. Now they fear bankruptcy and the loss of a l l they have worked for. There i s also the worry of the pending divorce from his f i r s t wife. Mrs. L. feels that her husband may go to j a i l i f he cannot pay the cost of the proceedings. Shortly before Lana's birth, Mr. L. had l e f t the family to return to his legal wife, who had threatened Court action to obtain support. Mrs. L. was quite i l l and placed Bob and Betty in non-ward care. The records show that the children were placed in a "low-grade" foster home and remained there for about three years until the agency contacted Mrs. L. through a newspaper advertisement. Mr. L. had returned by this time, and the family was reunited. Mrs. L. describes her husband as an easy-going man who i s exceptionally fond of his children. She said she and her husband have l i t t l e i n common, and cannot s i t down and discuss family matters. She feels desperately entrapped by their marital and financial entaglements. Mrs. L. describes herself as the "sickest member of the family." She broke off relationships with a l l her friends when she went to l i v e with Mr. L., for fear of their rejection, and she dis-appeared following the placement of the two older children. She has been very upset by their behaviour since their return from the foster home. Bob, especially, she hates. She has kept Lana very close to her, seeing herself i n this child, but feels that Lana i s fonder of her father than of her mother. Lana has never played with other children, and Bob and Betty have been made to give i n to her. 1-+5 Lana i s a f a t l i t t l e g i r l , with eczema, who i s c l i n g i n g and dependent on her mother. The psychologist reported that she tested i n the "average range of general i n t e l l i g e n c e " and did not show signs of gross disturbance. SCHEDULE L l f L 2 , The L. Family Schedule L, - Mr. L. Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-cal Role Legal wife's efforts to obtain financial support Independence, security 10 years Temporary desertion of Mrs. L. and children to return to f i r s t wife Husband Father Wife Child-ren Financial d i f f i c u l t i e s (pending bankruptcy and divorce costs) Independence, future 10 years ? Wife's anxiety about children's behaviour ? k years Hostility to wife ( i f she would stop y e l l -ing and not worry so much) Husband Wife Schedule L ~ - Mrs. L . Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Rec ipro -c a l Role Common-law r e l a t i o n s h i p Self-esteem, s o c i a l status 10 years Fear that people w i l l r e j ec t her—broke of f with a l l her f r i ends Member of Comm-unity Community E f f o r t s of husband's l e g a l wife to obtain support and h i s tem-porary desert ion Marriage, f i n a n c i a l s ecur i ty 10 years Anxiety , h o s t i l i t y , further i s o l a t i o n , i l l n e s s , g u i l t , placement of Bob and Betty with c h i l d wel -fare agency but clung to baby (Lana) Mother C h i l d r e n F i n a n c i a l d i f f i c u l t i e s , (struggle to es tab l i sh business , threatened bankruptcy, pending divorce costs) F i n a n c i a l s e c u r i t y , home, future 10 years Resentment—feels trapped by c ircum-stances and can do nothing about them, she i s " f u l l of hatred" Mother Wife C h i l d r e n Husband Husband's l ack of f i r m -ness with c h i l d r e n S e c u r i t y , authori ty H o s t i l i t y to husband, "If he would take a f irmer stand she woulc not have such a hard time " Wife Husband C h i l d r e n ' s disturbed behaviour plus her gu i l t f e e l i n g s , h o s t i l i t y (she i s "sickest member of family") Mother-image h years A p p l i c a t i o n to C l i n i c f i r s t f or Bob, but a l l c h i l d r e n event-u a l l y were treated Mother C h i l d r e n Schedule - Lana L. Age 6 Years Source of Stress Value Threatened Duration of Stress Response to Stress Major Role Impaired Recipro-cal Role Mother's withdrawal from social relationships, mother's unhappiness and anxiety (because of Mr. L.'s desertion), her i n -security, depression Security 6 years Insecurity, h o s t i l i t y , dependency on mother, (mother called i t a "strangling relation-ship"), conforming, controlled behaviour, eczema Daughter Mother Bob and Betty's return home from foster care when Lana was two or three plus her insecur-i t y Place i n family 3-k years Hostility, pushes Bob down, and fights with Betty i i i Sibling Sibling Material deprivation plus her anxiety, i n -security Security Since birth Acquisitiveness, re-fusal to share with other children Peer Peers Being sent to Day Centre day eroun plus her i n -security, dependency Security A few weeks Anxiety, h o s t i l i t y to other children (sep-arated herself from them and played alone), refused to return after she had been attacked by an-other child Peer Peers THE. L . F A M I L Y Ho-\" T i m b r e l ~ O HdC Kwovou - © P'tGr. - T ^ t ^ R - ^ O R t A P s t A C ^ t tA rAr\3"o*£- ^ O C I A W ^ o u ^ 150 Assessment Case XII Lana L. i s a six-year-old g i r l who i s showing considerable impairment i n s o c i a l functioning. Her r o l e as daughter i s moderately impaired, as s i b l i n g and student, extensively impair-ed, and as peer, severely impaired. Her reaction to stress has been to c l i n g more c l o s e l y to her mother, i n a r e l a t i o n s h i p re-f e r r e d to by Mrs. L. as "strangling." She shows much h o s t i l i t y to her brother and s i s t e r , f o r she resents sharing her mother with them. She fears new experiences and cannot r e l a t e to other children. The sources of stress have been the inadequate performance of both parents i n t h e i r f a m i l i a l r o l e s . At the time of her b i r t h , her parents had separated and the two older c h i l d r e n were placed i n non-ward care. Mrs. L., who was depressed and i l l and who had cut off a l l r e l a t i o n s h i p s with her f r i e n d s , encouraged Lana's dependency. The return of Bob and Betty to the home was an a d d i t i o n a l source of stress f o r t h i s c h i l d , f o r i t threatened her complete possession of her mother. Casework services appear to be required f o r the parents, the source of Lana's stress. Their degree of impairment would i n -dicate long-term service, directed i n the area of t h e i r marital and parental r o l e s . As Lana's impairment i n her peer r o l e i s so severe she cannot toler a t e group a c t i v i t y , i n d i v i d u a l casework 151 services may provide her with a r e l a t i o n s h i p i n which she has more stimulation and freedom to move towards greater maturity and independence. Chapter k THE SOCIAL ROLE THEORY - IS IT A USEFUL TOOL FOR ASSESSMENT? Redefining the Purpose of t h i s Thesis The purpose of t h i s thesis i s to examine the implica-tions of the s o c i a l r o l e theory by ap p l i c a t i o n to the assessment phase of casework practice. I t i s not the purpose to t e s t the v a l i d i t y of the concepts of ro l e and stress, but to attempt a p r a c t i c a l a p p l i c a t i o n of these concepts, as suggested i n the Curriculum Study, to the assessment phase of casework practice. Limitations of the Study Before an evaluation of the usefulness of the theory can be made, i t i s important to review some of the l i m i t a t i o n s of t h i s study. F i r s t , the case material had not been c o l l e c t e d or recorded with a view to examining the s o c i a l functioning of the c l i e n t and of those i n h i s immediate r o l e network i n terms of ro l e performance. While some reference was made to the per-formance of the c h i l d and h i s parents i n t h e i r major s o c i a l r o l e s , the primary focus was on those physical, psychological, mental and to a lesser degree, s o c i a l f a c t o r s which may have caused the emotional disturbance i n the c h i l d , the primary c l i e n t . Any change i n t h i s focus at the C l i n i c may involve some d i f f i c u l t i e s . I t i s usually the mother who makes the 153 application to the Clinic for help with her child. If the problem i s obviously a problem i n marital relationships, or in some other area which i s not considered appropriate to the function of the C l i n i c , the mother i s referred to the Family Service Agency or some other community resource. The cases that are accepted, are those where the children are emotionally disturbed and at least one parent appears motivated to become involved i n treatment. In the f i r s t few interviews, the focus i s generally kept on the problem of the child because this i s what the parents want to discuss, or at any rate, expect to discuss. This would seem to be i n conformance with the social work principle of "starting where the client i s . " It has been the experience of the Clinic staff that many of the mothers who apply are the dominant marital partners. Their husbands;who tend to be passive and withdrawn, have been more d i f f i c u l t to involve i n treatment. This may account for the fact that most of the early interviews are held with the mothers and there i s a scarcity of information about the fathers. As the relationship between the mother and worker strengthens, the focus i s grad-ually shifted to the parents' problems, marital relationships, and other areas of stress i n the family role network. The problem of changing the focus i s not insurmount-able, but careful, well-planned testing w i l l have to be done to determine how more information regarding social functioning i n terms of performance of major roles within the client's net-work can be obtained for assessment purposes. It may possibly 15*+ involve some r e v i s i o n of the s o c i a l h i s t o r y outline, which emphasizes the c h i l d ' s developmental h i s t o r y . And most important of a l l , i t w i l l involve a change of focus on the part of the worker. The Concept of Stress An examination of the analysis of the material on the basis of the concept of stress reveals how much the project was lim i t e d by t h i s focus i n early interviews on the c h i l d and his general emotional reactions to stress. This emphasizes that a d i f f e r e n t approach w i l l be necessary i f t h i s theory i s put int o practice. The sources of stress were c u l l e d by the writer from the records, often from a remark made by one of the parents. In some instances i t was impossible to gauge whether a c e r t a i n s i t u a t i o n , such as a c h i l d ' s early i l l n e s s , had r e a l l y caused stress, and t h i s would be d i f f i c u l t to determine no matter what the orientation of the worker. In t h i s Regard, i t was necessary f o r the writer to make some ar b i t r a r y decisions. The reactions to stress were usually described i n the records i n terms of emotional responses. Many of these were rather abstract g e n e r a l i t i e s — h o s t i l i t y , r e j e c t i o n , fearfulness, g u i l t — w h i c h terms were repeated again and again. In some instances, there was reference to psychosomatic i l l n e s s , an emotional-physical response. In a few cases, p a r t i c u l a r l y with the c h i l d r e n , the assessment had been car r i e d to the extent that 155 there was some explanation of how the c h i l d ' s behaviour was affected by these emotional reactions. The school reports, i n the cases where these had been obtained, usually stated i n a fo r t h r i g h t manner how the ch i l d ' s behaviour was impairing h i s performance but of course did not explore the sources of stress. P a r t i c u l a r l y with respect to the adults, however, there was l i t t l e c l a r i f i c a t i o n of how these emotional responses were r e a l l y a f f e c t i n g the person's r o l e performance. Neither was i t clear how t h i s reaction was helping the i n d i v i d u a l maintain the l e v e l of s o c i a l functioning which existed p r i o r to the occurrence of s t r e s s — a n inherent feature of the concept of stress. A r e a l e f f o r t was made to search out t h i s information, but as i s i n -dicated by the analyses, the re s u l t s were not too s a t i s f a c t o r y . Concept of Role The analyses using the concept of role also show the li m i t a t i o n s imposed by the material used. In several cases, nothing was known about the person's re l a t i o n s h i p s outside the immediate family group. I t i s worth emphasizing that there are thi r t e e n question marks on the charts f o r community member or peer r o l e . Even within the family, l i t t l e was known of the performance of the s i b l i n g i n many cases. There was l i t t l e to indicate the expectations of the parents with regard to t h e i r c h i l d r e n , other than t h e i r complaints, which indicated t h e i r expectations were not being met. There was l i t t l e , too, to indicate the parents' expectations of themselves or of each other. The emphasis was primarily on the mother-child r e l a t i o n -s h i p , and as noted previously, i n some cases information about 156 the father was rather sketchy. M a r i t a l relationship; was an unexplored area i n some instances, i n t h i s early phase of treatment. This confirms the previous comment that i f t h i s theory i s to be put i n t o practice, a d i f f e r e n t approach must be u t i l i z e d i n the f a c t - f i n d i n g process—an approach that w i l l extend beyond the present emphasis on the c h i l d ' s developmental h i s t o r y , although, of course, t h i s cannot be overlooked. S o c i a l functioning i s the product of i n t e r a c t i o n among intrapsychic, somatic and s o c i a l forces, Any assessment of s o c i a l functioning therefore, must take a l l these factors into account. The l i m i t a t i o n s of t h i s study, primarily lack of s u f f i c i e n t information and the necessity of making a r b i t r a r y decisions, have been described i n some d e t a i l because they must be considered i f an objective evaluation i s to be made. Evaluation of the A p p l i c a b i l i t y of Theory to Casework Practice At the r i s k of overemphasizing the negative, i t seems relevant to discuss some of the d i f f i c u l t i e s which emerged i n the application of the concepts. Whether these problems r e -present l i m i t a t i o n s of, or areas of ambiguity i n the theory, or l i m i t a t i o n s of knowledge and understanding on the part of the writer, i t i s hard to determine at t h i s point i n time. But i f there were other ways of dealing with these problems, the writer was unable to discover them. The f i r s t was the problem of tracing back the reaction to stress to some p a r t i c u l a r source of stress. As was mentioned 157 i n Chapter 2, the reaction, i n most instances, seemed to be a cumulative one. The mother's impairment i n her r o l e of mother, fo r example, seemed to stem from her e a r l i e r l i f e experiences and her reaction to them, and then from an accumulation of various stresses. A c h i l d ' s temper tantrums, eneuresis, poor school progress, seemed to be a general response to a l l the stresses imposed on him. This may have been due i n part to d i f f i c i e n c i e s i n records and the f a c t that the workers were, .not attempting to ascertain the information, which would point to the importance of a t h e o r e t i c a l perspective to f a c t gethering. Whether t h i s i s the case, or whether i t i s possible to determine the p a r t i c u l a r source of stress which has caused a c e r t a i n reaction, i s a point that requires more c l a r i f i c a t i o n . The second major problem was with regard to the r o l e concept. The writer, whose orientation has been the h o l i s t i c view, found i t d i f f i c u l t to consider an i n d i v i d u a l i n terms of various r o l e s . At f i r s t i t seemed to e n t a i l , t h e o r e t i c a l l y at l e a s t , a s u r g i c a l operation f o r each person—a cutting up on the whole into parts. Much of the d i f f i c u l t y was undoubtedly caused by the very general descriptions of reaction to stress, such as " h o s t i l i t y . " I t was d i f f i c u l t to determine what s o c i a l r o l e s were most affected, i f , f o r that matter, they were affected at a l l . As the project developed and the writer became more orientated to the use of the concept, she r e a l i z e d that i t did not c o n f l i c t with the h o l i s t i c view. The solution would seem to be to obtain from the c l i e n t or others i n h i s r o l e 158 network, some c l a r i f i c a t i o n about how h i s performance i n various roles i s affected by stress. A t h i r d problem, and t h i s appears to be more complex, was with regard to the ro l e s themselves. The s p e c i f i c r o l e s , mother, son, husband, c l e a r l y f i t the d e f i n i t i o n of r o l e i n s o c i a l r o l e theory (see p. l * f ) . But so do the general r o l e s , the r o l e of student, or community member, or worker (which was l a b e l l e d "employee" i n t h i s paper). General r o l e s , however, have no one r e c i p r o c a l r o l e . In the case of role of student, the r o l e of teacher i s the one l o g i c a l r e c i p r o c a l r o l e . The ' other students, however, are also i n the picture f o r i f a c h i l d cannot get along with h i s fellow students, or h i t s them, or d i s t r a c t s them, h i s role of student w i l l be impaired. I f a c h i l d i s making l i t t l e academic progress because of h i s low i n t e l l e c t u a l a b i l i t y , t h i s factor can be considered a determin-ant of r o l e . (In one case, the teacher said the c h i l d was no problem and was doing well considering h i s l i m i t e d i n t e l l i g e n c e . There was no impairment of the student-teacher r e l a t i o n s h i p be-cause of h i s poor academic progress, although h i s parents and society generally might consider h i s performance i n the r o l e of student impaired.) But i f a c h i l d i s doing poorly academically and has a superior i n t e l l i g e n c e r a t i n g , one cannot deny h i s role of student i s impaired. This may or may not a f f e c t the student-teacher r e l a t i o n s h i p . Therefore, the r o l e of student must take i n t o consideration more than the student-teacher-relationship. In other words, f o r some rol e s there may not be a r e c i p r o c a l 159 r o l e , and r e c i p r o c a l r o l e s are a major feature of the concept of r o l e . I t i s poss ible that the w r i t e r attempted to use the concept too broadly by combining many s p e c i f i c r o l e s in to one general r o l e . In the case of the self-employed husbands, at l e a s t two poss ible r e c i p r o c a l r o l e s , both inc lud ing many i n d i v i d u a l r e l a t i o n s h i p s can be perceived. One i s the r o l e of customer or c l i e n t , another i s business a f f i l i a t e . But an examination of performance i n e i ther of these r o l e s may not give us a c l ear p ic ture of the person's performance i n h i s r o l e of businessman. I t would seem that the r o l e concept requires c l a r i -f i c a t i o n i n t h i s regard i f i t i s to be used by s o c i a l workers. This study has h igh l ighted some of the problems that may be encountered when a serious e f f o r t i s made to apply the theory to casework p r a c t i c e . The sources of s t r e s s , value threatened and react ion to stress i n terms of r o l e impairment w i l l need to be c l a r i f i e d . And the focus must be on the c l i e n t ' s s o c i a l funct ioning i n terms of performance of major r o l e s and on the s o c i a l funct ioning of those i n h i s r o l e network. This would ind ica te an extension of the f a c t - f i n d i n g process to determine the adequacy of performance i n a l l major r o l e s . As was noted prev ious ly , some experimentation w i l l be required to determine how th i s can best be done. This problem may vary somewhat i n d i f f erent se t t ings . In a fami ly serv ice agency, where the presenting problem i s often m a r i t a l c o n f l i c t , i t may be eas ier 1 6 0 to obtain information about parents* t o t a l r o l e performance, but more d i f f i c u l t to obtain information about the c h i l d r e n . In a public welfare agency, where the c l i e n t s are requesting f i n a n c i a l ass i s tance , the explorat ion of t o t a l s o c i a l funct ioning may present some problems. In any s e t t i n g , an explorat ion of the adequacy of performance i n a l l major r o l e s i n the ear ly f a c t -f ind ing phase would not only necess i tate a d i f f e r e n t focus on the part of the worker but may arouse a d d i t i o n a l resentment and res i s tance on the part of the c l i e n t . This i s a very r e a l p o s s i b i l i t y that cannot be overlooked. Resistance may be m i n i -mized by an ear ly c l a r i f i c a t i o n of r o l e expectations between worker and c l i e n t . Role confusion would thus be e l iminated for the c l i e n t would be aware of what was expected of him and what he could expect from the worker, representing the agency. Evaluation, Qh flW B a s 4 § of qr i ter- ja The second basis on which the theory i s to be evaluat-ed i s whether i t meets the c r i t e r i o n , mentioned i n Chapter 1 , of enabling caseworkers to help the c l i e n t more e f f e c t i v e l y . In t h i s study the concepts of s tress and r o l e have been used i n combination f o r assessment purposes. But l e t us f i r s t look at the concept of s tress i n r e l a t i o n to the small sample of case record mater ia l used i n t h i s t h e s i s . In a l l cases, the a p p l i c a t i o n of t h i s concept helped to i d e n t i f y the sources of s t re s s . And even more important, i t helped to c l a r i f y whether the s tress was i n t e r n a l or ex terna l . The use of t h i s concept,-161 therefore , suggests options i n treatment—whether to work with the c h i l d i n the area of react ions to s tress or with the par-ents , i n the area of t h e i r force as a s tress f a c t o r . The durat ion of s tress and m o d i f i a b i l i t y of the s tress fac tor help to determine the form of treatment and l e v e l of treatment. There i s one important feature that has been mentioned previous ly i n th i s study, but bears repeat ing . The r e a c t i o n to s tress must be perceived by the worker i n terms of whether or not i t impairs s o c i a l func t ion ing . According to the Curriculum  Study, s o c i a l casework's purpose i s to help the c l i e n t achieve more e f f ec t ive r o l e performance. Thus the i n t e r p r e t a t i o n of the reac t ion must be i n terms of r o l e performance, and not i n terms of general emotional r e a c t i o n s , such as "fearfulness ." The worker must go one step f a r t h e r , and assess whether or not t h i s reac t ion i s impairing the c l i e n t ' s r o l e performance, and which ro les are impaired and which threatened. The concept of s tress used together with the concept of r o l e would seem to provide a much broader, more comprehensive assessment of the c l i e n t i n r e l a t i o n to h i s problem than current prac t i ce usual ly provides . In t h i s study the approach was through the concept of s tress to the concept of r o l e . The c l i e n t ' s inner s e l f was examined f i r s t to determine how and where i t had af fected per-formance of h i s outer s e l f . This was done because of the nature of the mater ia l used. The wr i ter would suggest that a more f r u i t f u l and d i r e c t approach would be through the concept of r o l e . 162 The f i r s t step would be to examine social functioning i n major social roles and move on from this to an investigation of the sources of stress which have caused impairment. A f u l l e r understanding of the concept of role would lead the worker to look not only at the client's psychic structure, but f i r s t of a l l , at his whole role network. This focus on the role network might give the worker a better under-standing of which member i s most i n need of help. A study of the chart depicting the role performance of the A. family i n -dicates that Mr. A.'s poor performance i n his marital and parental roles i s indeed a source of stress to Mrs. A. and to Alan. While i t i s possible that Mr. A. may not become readily involved i n treatment, an understanding of his performance would enable the worker to be of more help to Mrs. A. and the child. Of particular interest, i s the fact that the study highlights a role which i s often neglected i n assessment and treatment process—the role of sibling. This, i n i t s e l f , could be the area of a good deal of study. In the small sample of cases used in this thesis, six of the total of twelve children exhibited severe impairment i n their sibling role. The parents' diffe r e n t i a l treatment of their children was a factor in some cases, and this may be modified through casework service to the parents. There i s some indication, however, that impair-ment i n the reciprocal role of sibling may also be a source of 163 stress to the c h i l d - c l i e n t . Unless there i s some modi f icat ion i n t h i s s tress f a c t o r , treatment of the c l i e n t may be impeded. The wr i t er could f i n d very l i t t l e reference to s i b l i n g r e l a t i o n -ships i n the l i t e r a t u r e . Dr . Alan Cashmore, c h i l d p s y c h i a t r i s t at the C l i n i c , confirmed that t h i s v a s t l y important area of r e l a t i o n s h i p remains r e l a t i v e l y unexplored. Probably the most s i g n i f i c a n t feature of the s o c i a l r o l e theory, and t h i s i s best ind icated by the r o l e performance c h a r t s , i s that i t would seem to be an exce l lent t o o l f or fami ly assessment. The profess ion has been aware of the need for diagnosing family groups, but u n t i l now, there have been no theories which have provided the key. Psychoanalytic theory provided a means f o r a better understanding of the dynamics of the i n d i v i d u a l — a necessary step i n t h i s development. Now the profess ion seems to be on the verge of the next great advance, a better understanding of family dynamics. Resistance to new theories and new concepts would seem i n e v i t a b l e and some res i s tance by s o c i a l workers to t h i s new theory may be expected. Comments made to the w r i t e r by prac t i s ing workers, however, have pointed out several s p e c i f i c areas of re s i s tance . One i s the concern that the psychoanalytic theories may be d iscarded. Another i s that th i s theory provides nothing new but the jargon. This study ind ica tes that the concepts of psych ia try , p a r t i c u l a r l y the ones c l u s t e r i n g around ego-psychology, are f i r m l y maintained. The d i f ference 16M-i s that they become part of a more encompassing and more cohesive whole. The tremendous contribution of the s o c i a l r o l e theory i s that i t leads from an understanding of i n d i v i d u a l dynamics to an understanding of family, group and eventually community dynamics. While i t u t i l i z e s psychoanalytic and ego psychology theories, i t has integrated them with s o c i o l o g i c a l theories, or i n other words, has put our understanding of i n d i v i d u a l dynamics i n a s o c i a l context. Thus i s provided a better balanced perspective of man i n r e l a t i o n to society. APPENDIX A Diag^QSt-'jc, Conference Alan A. " C l i n i c a l f i n d i n g s — s e e copy of psychological report. Alan i s described as an appealing c h i l d but more demanding than usual. He wants to show o f f , seeks a great deal of reassurance, i s intensely insecure, and concerned about himself. His i n t e l l i g e n c e i s very superior, h i s mental age being 7 years and 6 months on the Binet Test. He showed attention seeking and s i l l y mannerisms as described by mother. He said he hated to go home and i t was hard to get him to leave. He responds to firmness. He c i t e d one of h i s bad dreams—describing a witch with two children. They f e l l through a hole and mother got one back, and the other was eaten up. He proved s e n s i t i v e , t r i e d to avoid looking at r e a l f e e l i n g s and became angry i f encouraged to do so. Tests revealed an extreme degree of s i b l i n g r i v a l r y ; that he f e e l s l e f t out and that a l l parents' attention and love go to Brian. He indicated that he i s lonely and not deriving s a t i s f a c t i o n from peer r e l a t i o n s h i p s . I t was considered that Alan's problems stem from the separation from h i s mother at age two and her e a r l i e r un-happiness, and from h i s succession of traumatic experiences: at age four, meningitis and returned from h o s p i t a l to f i n d the new baby; tonsilectomy and attendance at play school. It was considered that he would respond well to i n d i v i d u a l therapy and that he might be put on the l i s t f o r Day Centre f o r Children. He w i l l be assigned to a therapist as soon as one i s a v a i l a b l e . During the i n t e r v a l , i n d i v i d u a l interviews w i l l be ca r r i e d on with the mother. I t was considered that she would respond to help and be able to e f f e c t some amelioration i n the family s i t u a t i o n . " Bob B, "The p s y c h i a t r i s t saw Bob as a reasonably average youngster. He expressed some rather f a n c i f u l material which i t was d i f f i c u l t to t e l l whether i t had any f a c t u a l base or not. He was taken up with the idea of being a protector. He spoke of a tutor, a Chinese and Spanish lady. He emphasized punishment and s t r i c t n e s s . The psychologist found that Bob responded to her i n . an immature manner and though he cooperated f a i r l y w e l l , he became r e s t l e s s with increasing demands. He showed dependent, 166 coy and attent ion-seeking behaviour. He i s funct ioning low i n the average range of general i n t e l l i g e n c e . He was threaten-ed and became se l f -consc ious when presented with emotionally charged m a t e r i a l . He general ly fears r e l a t i o n s h i p s and i s emotionally immature and d i s s a t i s f i e d . He sees h i s parents as fearsome people. There i s a great deal of emphasis on spankings and punishment. He i s e s p e c i a l l y h o s t i l e to mother whom he sees as a very d i r e c t i v e and unhappy person. Treatment: C h i l d and parents both to be assigned to workers." C a r l C . "Psychologist reported that C a r l was cooperative and t r i e d hard i n doing psychologica l t e s t s . Hi s reading i s exceedingly poor and brings down h i s r a t i n g . He i s immature, shows lack of c o n t r o l and anxiety around m u t i l a t i o n . He tested i n the low border l ine group i n some areas but general ly should be rated as slow normal. Psychologist considered he would best be treated i n an i n s t i t u t i o n a l se t t ing over a long period of t ime, as h i s amount of inner strength i s i n quest ion. He has a minimal amount of c o n t r o l over h i s impulses. He show-ed d i f f i c u l t y accepting male i d e n t i f i c a t i o n . P s y c h i a t r i s t questioned the p o s s i b i l i t y of h i s having post -encephal i t i c damage of h i s temporal lobe and suggested an E . E . G . I t was noted that h i s h i s t o r y was traumatic and h i s disturbance cons iderable . C l i n i c a l diagnoses i s 'character d i s o r d e r . ' A c e r t a i n amount of transvest ic i sm i s normal for adolescence. Further conference w i l l be held when r e s u l t s of E . E . G . are obtained. I t could be questioned whether C a r l has a personal i ty disorder or a trans ient pervers ion t i e d up with temporal lobe abnormality." Subsequently an E . E . G . was done and the p s y c h i a t r i s t accepted C a r l f or treatment at the C l i n i c . Don D. "Soc ia l worker and p s y c h i a t r i s t out l ined progress to date with Don and mother. Don was seen as an appeal ing , br ight c h i l d , who has a l o t of problems around h i s r e l a t i o n s h i p s with both parents. He seems to have a l o t of c o n f l i c t i n the anal area and the p s y c h i a t r i s t suggested that mother's a t t i tude towards t h i s be explored. Mrs. D. was seen as quite an i n t e l l i g e n t woman with a passive-aggressive type of adjustment, with many psychosomatic symptoms. S o c i a l worker expressed some concern about much intense explorat ion of Mrs. D.*s f e e l i n g s , which are not r e a d i l y ava i lab le because of her tendency to react through 167 i l l n e s s when under too much pressure, but f e l t mother could benefit from support and acceptance of h e r s e l f , as w e l l as some explorat ion of her r e l a t i o n s h i p with Don and suggestions re handl ing . The case was seen as f a i r l y short-term and w i l l be reassessed i n three months." Eva E . "The p s y c h i a t r i s t reported her interview with Mrs. E . She thought that Mrs. E . was very ambivalent about coming to the C l i n i c . She spoke of Eva as being a very sens i t ive c h i l d . Mrs. E . also stated that her husband i s too soft with the c h i l d r e n and leaves the d i s c i p l i n i n g to her . The p s y c h i a t r i s t f e l t Mrs. E . had a great need f o r the c h i l d r e n to be success-f u l s ince she d id not f i n d the fa ther successful i n h i s work. The psychologist reported that Eva was s u p e r f i c i a l l y f r i e n d l y and has a tomboyish manner. She t r i e s to appear casual and at ease but i s quite an anxious g i r l and became more and more evasive. She became threatened when things were d i f f i c u l t to do and she was re luc tant to express h e r s e l f v e r b a l l y . She i s funct ioning i n the average range of general i n t e l l i g e n c e . There was d i f f i c u l t y i n v i s u a l motor coordina-t i o n and Eva became confused and disorganized and discouraged when presented by such m a t e r i a l . She was seen to be an immature and insecure g i r l . She i s d i s s a t i s f i e d with h e r s e l f and with l i f e i n the fami ly . There i s evidence of h o s t i l i t y to others and she resents t h e i r r e s t r i c t i o n s and c o n t r o l s , e s p e c i a l l y maternal . There was a lso evidence of vague apprehension which may be r e l a t e d to concern about her feminine r o l e . R e l a t i o n -ships with people have offered very l i t t l e s a t i s f a c t i o n and Eva i s denying her a f f e c t i o n a l needs. Eva was r e s e n t f u l and d id not want to recognize problems. She i s not h igh ly motivated to seek change for h e r s e l f . Her reading was w i t h i n the normal range but she had a problem i n concentrat ing . The p s y c h i a t r i s t saw Eva and found that her r e l a t i o n -ships were not s a t i s f y i n g to her . Eva wants to get away and look a f ter animals i n a remote r u r a l area . She tends to be hypochondrical . She t o l d the p s y c h i a t r i s t she was not worried about school or home. She mentioned that she l i k e d to play with a boy i n the neighborhood but her parents discouraged i t as the boy was effeminate. She tends to be in teres ted i n gang a c t i v i t i e s . Discuss ion: The p s y c h i a t r i s t f e l t that Eva was e i ther bored, preoccupied with fantasy or depressed. I t was noted that most of her h o s t i l i t y i s d i rec ted towards her mother. I n t r a -f a m i l i a l c o n f l i c t s cause her to want to escape. The psychia-t r i s t wondered i f Eva had s tarted to menstruate and worker was not sure about t h i s . 168 Recommendations: I t was recommended that Mr. and Mrs. E . be seen by present worker and that Eva a lso be seen f o r t r e a t -ment i f she can be engaged i n treatment. I t was thought she might respond better to a male." Frank F . "Discussion was he ld around parent's phys i ca l symptoms and the p s y c h i a t r i s t suggested i t might be h e l p f u l to go in to what p r e c i p i t a t e d Mrs. F . ' s migraine headaches (repressed h o s t i l i t y often the cause) . I f she understands what causes them she may be able to delay them. Regarding Mr. F . ' s duodenal u l c e r s , dependency and f r u s t r a t e d ambition are sa id to be prominent persona l i ty t r a i t s of people suf fer ing from t h i s cond i t i on . The s o c i a l worker f e l t that he needs occas ional ly to "explode" and that Mrs. F . and Frank might be helped to understand t h i s . Regarding Frank, the psychologist found him to be much more subdued and unproductive than the average eleven-y e a r - o l d . He evidenced anxiety i n r e l a t i o n to both parents and confusion i n h i s i d e n t i f i c a t i o n . He uses p r o j e c t i o n and d e n i a l a good dea l and compared to Lou i se , would take longer to he lp . Psychologist sa id he showed excessive c o n t r o l and lack of spontaneity. S o c i a l worker wondered whether the mother's fears of Frank lo s ing c o n t r o l and ser ious ly hurt ing someone were r e a l i s t i c and psychologist thought i t would take a l o t to lose c o n t r o l to t h i s extent, although Frank i s f e a r -f u l of c lose r e l a t i o n s h i p s and of what he might do. I n t e l l e c t u a l l y , Frank tested low br ight normal (min i -mal r a t i n g ) . The psychologist sa id Frank seems sens i t ive to people and can r e l a t e . Rec ommendations: ! • Frank to be seen by a male worker for supportive therapy and l i m i t e d aims f o r one year . Case to be assessed re terminat ion or cont inuat ion at that t ime. 2. Louise to be seen by new res ident p s y c h i a t r i s t . I t was f e l t that she i s a br ight responsive c h i l d who w i l l respond w e l l to treatment. 3» Parents to continue j o i n t interviews f o r the present with the p o s s i b i l i t y of i n d i v i d u a l sessions i f i n d i c a t e d . k. In view of the f a c t that three people and the p s y c h i a t r i s t w i l l be working on t h i s case, monthly conferences were suggested." 169 Gordon. Q, "The s o c i a l worker reviewed the case and team members added t h e i r f i n d i n g s . The p s y c h i a t r i s t sa id that Gordon had not been communicative with him. He d i d not see Gordon as a ser ious ly d is turbed boy. He saw him to be a very l a r g e , awk-ward boy who saw h i s mother as puni t ive and c o n t r o l l i n g , Gordon was near tears as he spoke of h i s poor progress i n school . He sa id that he wanted to be a mechanic but he f ee l s hopeless about gett ing the academic requirements. The p s y c h i a t r i s t saw Gordon as an unmasculine, sexual ly passive boy. The psychologist stated Gordon was anxious but t r i e d to c o n t r o l h i s anxiety . He d i d become l e s s anxious i n the second interview. He was cooperative and anxious to please and needed support to continue. Gordon was completely unable to draw the female f i g u r e at a l l and showed great anxiety with regard to t h i s , being near t ears . Gordon tested i n the border l ine range of general i n t e l l i g e n c e and t h i s r a t i n g would seem to be minimal as anxiety i s i n t e r f e r i n g with h i s f u n c t i o n -ing* His verba l r a t i n g was i n the d u l l normal range of general i n t e l l i g e n c e and h i s performance was i n the defect ive range. His reading i s at the Grade k l e v e l . The psychologist assess-ed Gordon as immature and inadequate, evasive and f l a t t e n e d . He i s very discouraged and i s confused about h i s i d e n t i t y . He sees being female as more advantageous than being masculine. He i s lack ing i n s a t i s f y i n g r e l a t i o n s h i p s . He sees h i s mother as c r i t i c a l and d e p r i v i n g . He does have an awareness of values . I t was f e l t that Gordon and Jim both need masculine i d e n t i f i c a t i o n and that t h i s could be given to them through a male person i n t h e i r environment. I f no su i tab le male can be found the p s y c h i a t r i s t suggested that poss ib ly one therapi s t could take on Gordon and Jim together for interviews and poss ib ly Joe could be included i n t h i s . The team f e l t that remedial academic work would be h e l p f u l at some po int . I t was a lso suggested that Gordon might get i n t o Vocat iona l School even i f he does not have Grade X s tanding." Howard H . "The psychologist reported Howard tested i n the border l ine range of general i n t e l l i g e n c e . He i s unable to read through a paragraph but can make out some of the words, i s not doing as we l l as he should. He i s immature, insecure and emotionally deprived. Howard shows p o s i t i v e f ee l ings towards male f i g u r e s , does not get s a t i s f a c t i o n out of r e l a t i o n s h i p s , i s pre-occupied with death and fear of los s of a l l sources of s a t i s f a c t i o n . Howard expressed anxiety about parenta l r e l a t i o n s h i p s . 170 The p s y c h i a t r i s t found Howard f e a r f u l , anxious, depressed. The mother appeared tense, talked of t r a n q u i l l i -zors . Says she cannot get cross with Howard or he reacts with abdominal pains and headaches. Too much change i n mother cannot be a n t i c i p a t e d . A supportive l e v e l of treatment was recommended. The school should be advised they are doing w e l l with Howard and should not be too permissive. They could be ad-v ised that the c h i l d i s unhappy and should improve i n h i s work as h i s fami ly r e l a t i o n s h i p s improve under treatment." Ike I . "The p s y c h i a t r i s t found Ike to be a hard c h i l d to get through to . He showed a l o t of t e s t i n g , c o n t r o l l i n g and pass ive ly aggressive behaviour. He was very ac t ive but there was a looseness and d i sorganiza t ion about h i s p lay . He played by himself and d id not inc lude the t h e r a p i s t . He had a pronounced s t u t t e r , regress ive speech, reverted to baby t a l k . The psychologist found that i n a s tructured interview Ike tended to be quite cooperative but i f anything was too hard to do, he tended to be evasive. When pressured to t a l k about f e e l i n g s , he s tut tered a great d e a l . He tested high i n the border l ine range of general i n t e l l i g e n c e and i s poss ibly p o t e n t i a l l y of average i n t e l l i g e n c e . He i s confused, mixed-up, unhappy, unsure of h i s own i d e n t i f i c a t i o n and insecure . He seems to be t r y i n g to deny h i s need for a f f e c t i o n and acceptance from others but does show some a b i l i t y to respond and to look for a warmer r e l a t i o n s h i p with a maternal f i g u r e . I t was decided before we determine what treatment to o f f e r , the p s y c h i a t r i s t would check with the fami ly doctor re epi lepsy and medicat ion." Jean J . "Much of the d i scuss ion i n th i s case centred around the problem of mother, Mrs. J . In d iscuss ing Jean, the p s y c h i a t r i s t sa id she i s an emotionally deprived c h i l d who has had poor r e l a t i o n s h i p s with both parents , but mother e s p e c i a l l y . In view of Mrs. J . ' s i n a b i l i t y to give to Jean and i n view of Jean's ear ly h i s t o r y of d i s turbances , e . g . , c o l i c , method of weaning, i l l n e s s — t h e r e was some question as to Jean's a b i l i t y to respond to treatment. However, both p s y c h i a t r i s t and psychologist noted a r i c h fantasy l i f e i n Jean, and much surface h o s t i l i t y , and i t was f e l t that these were favorable ind ica t ions of t r e a t a b i l i t y . 171 Jean appears to have much sexual concern and c u r i o s i t y regarding r e l a t i o n s h i p s between men and women and i s confused about her own sexual i d e n t i f i c a t i o n . The p s y c h i a t r i s t stated that i t was d i f f i c u l t to speculate on Jean's s o i l i n g u n t i l more i s known about the mother's problem. However, he f e l t the s o i l i n g d i d appear to represent a regress ion from the oedipal c o n f l i c t . Regarding Mrs. J . , the general f e e l i n g was that she w i l l be d i f f i c u l t to t r e a t as her problems seem to be l a r g e -l y those of the obsessive-compulsive. She i s d i sp lay ing a c l a s s i c symptom of the obsessive's i n a b i l i t y to t a l k about problems i n that her speech i s h a l t i n g and hes i tant and she does not even f i n i s h sentences at times. The p s y c h i a t r i s t f e l t that her athsma and stammering are r e l a t e d . F u r t h e r , Mrs. G . ' s concern over Jean's tomboyishness i s l i k e l y a r e s u l t of her own confusion re sexual i d e n t i f i c a t i o n . I t was f e l t by those present that the best approach to take with Mrs. J . at present was a supportive one, rather than a deeper method of treatment, as she i s at present incapable of d iscuss ing her own problems because of her ambivalence and c o n f l i c t . " Ken K. "The p s y c h i a t r i s t suggested that i f the mother i s l e f t untreated she could have another psychotic episode. She shows schizophrenic tendencies and has insiduous paranoia. He suggested to mother that she attend Day H o s p i t a l i n the Adult C l i n i c and at same time, boys can attend Day Centre for C h i l d r e n . Mother sees her own des truc t ion and that of the family as i n e v i t a b l e and seems to be working toward that end. She i s d i s s a t i s f i e d with married l i f e and may eventual ly want to leave home. The psychologist found Ken exceedingly i n h i b i t e d and fr ightened . He proved cooperat ive . His reading i s poor. He measured low i n the average range of i n t e l l i g e n c e . He showed a lack of good r e l a t i o n s h i p with May. P s y c h i a t r i s t mentioned Ken's r e l a t i o n s h i p with mother i s a symbiotic one. I t was agreed that Ken should be accepted f o r treatment and should be considered f o r Day Centre . The p s y c h i a t r i s t w i l l see mother and s o c i a l worker, the fa ther . Ken i s a s i x - y e a r - o l d emotionally d is turbed c h i l d of average i n t e l l i g e n c e who has parents and grandparents on both sides who have suffered or are suf fer ing emotional d i s t u r b -ances. His behaviour i s i n response to h i s f a t h e r ' s over-concern and to mother's s i m i l a r habi t s and h i s i d e n t i f i c a t i o n with her . The f a m i l y ' s withdrawal from the community and May's overprotect ion enter the s i t u a t i o n a l p i c t u r e . There was evidence of h o s t i l i t y turned inward and of g u i l t . There are pregen l ta l neuroses fac tors present ." 172 frana It* "Very l i t t l e i s known about Lana*s ear ly develop-mental h i s t o r y as mother has not considered Lana a problem and dismisses i n q u i r i e s by s tat ing that Lana does not r e a l l y need treatment. Lana s tarted at Day Centre o r i g i n a l l y , p a r t l y be-cause of our need for more g i r l s i n the program and p a r t l y because of the problem of interviewing mother when Lana was along. She was having d i f f i c u l t y i n separating from mother and would not s i t i n the wait ing room by h e r s e l f . Mother has never r e a l l y considered her much of a problem. I t was f e l t by the psychologist that Lana does not show too much d i s t u r b -ance. The p s y c h i a t r i s t pointed out that the mother seemed to f e e l that our in teres t i n Lana might d i l u t e our i n t e r e s t i n Bob. I t was f e l t that we should continue with Lana, at l eas t to see her through the s t a r t i n g of school . Lana w i l l , therefore , be seen for another three months and mother w i l l be assured that our p r i n c i p a l i n t e r e s t i s i n Bob and i n h e r s e l f . " APPENDIX B Rating Scale f o r Measuring Performance i n Peer Role ( i f c h i l d ) and Member of Community Role ( i f adul t ) Role C r i t e r i a S o c i a l Funct ioning Not Impaired Moderately Impaired Severely Impaired Fr i end Makes f r i e n d s with r e l a t i v e ease and maintains f r i e n d -ships . Does not force h i s opinions upon others and respects t h e i r opinions . Makes few f r i ends or makes f r i ends but cannot keep them. Finds l i t t l e i n common with those of h i s own age group, sex and s tatus . Shy or overbearing. Has no c lose f r i e n d s ; f e e l s marked-l y i n f e r i o r ; d i s t r u s t f u l ; quarrelsome; withdrawn. Neighbour F r i e n d l y , cons id -erate and cooper-a t i v e . Neither imposes on neighbours nor allows himself to be imposed on by them. Reserved, uncoop-e r a t i v e ; has few deal ings with neighbours. Does not communicate with ne igh-bours. Withdrawn, d i s t r u s t f u l , unfr iendly or very i n -cons iderate . May cause t rouble . P a r t i c i p a -t ing Enjoys companion-ship of others . Takes some r e -s p o n s i b i l i t y as a member of soc ie ty by contr ibut ing time and ta lent to at l e a s t one community organiza-t i o n . I f a c h i l d , enjoys one or two group a c t i v i t i e s appropriate for age. Fee l s l i t t l e r e s p o n s i b i l i t y f o r welfare of soc i e ty . May belong to one or two groups but i s a non-act ive member. I f a c h i l d , does not p a r t i c i p a t e i n group play . Does not belong to any community organizat ions or groups. I f a c h i l d , cannot p a r t i c i p a t e i n group a c t i v i t i e s . Member of Community Groups 17-+ Rating Scale f o r Measuring Performance i n Employee Role Role S o c i a l Funct ioning u n i e r i a Not Impaired Moderately Impaired Severely Impaired R e l a t i o n -shi D with Employer Respects employer and i s respected by him; l o y a l ; not f e a r f u l of expressing him-s e l f but i s not antagonis t i c . Fee l s he i s not get t ing a f a i r dea l ; covert d i s s a t i s f a c t i o n . Dependent; antagonis t i c ; frequent ly leaves jobs. Tra in ing and, S k i H U n i v e r s i t y or high school and good vocat iona l or i n - s e r v i c e t r a i n i n g . F inds opportunit ies to improve h i s know-ledge and s k i l l s . High school edu-c a t i o n or some vocat iona l t r a i n i n g . Makes l i t t l e r e a l i s t i c e f f o r t to improve h i s knowledge or s k i l l . D id not com-plete high school; no s p e c i a l t r a i n i n g or s k i l l ; no e f f o r t to improve h i s q u a l i f i c a -t i o n s . Interest Vocation Finds job s a t i s -fy ing and cha l l eng ing . Contributes new ideas and new techniques to improve standard or quantity of work. Works for wages only and h i s l i t t l e i n t e r e s t i n job. Not i n t e r e s t -ed. Has frequent periods of unemployment. 175 Rating Scale for Measuring Performance i n Husband Role Role C r i t e r i a S o c i a l Funct ioning Not Impaired Moderately-Impaired Severely Impaired Source gmp.tlQnaJL Support Expresses a f f e c -t i o n for wi fe . Gives her secur-i t y and freedom from anxiety . Shows an i n t e r e s t i n her a c t i v i t i e s , her c r e a t i v i t y , her work and her needs, both emotional and p h y s i c a l . Has selected wife with good feminine i d e n t i f i c a t i o n and accepts her more dependent r o l e . Expresses l i t t l e a f f e c t i o n . Can perform w e l l when own needs are met but has a low threshhold of f r u s t r a t i o n . E a s i l y threatened. Has trouble sharing wife with c h i l d . Not much a b i l i t y to perceive wife ' s needs and no a b i l -i t y to put them before h i s own. Gives no evidence of a f f e c -t i o n . E i t h e r overly pass-ive or dom-ineer ing or shallow and s u p e r f i c i a l . Without a b i l i t y to perceive needs of wife; demands without g iv -i n g ; n a r c i s s i s t i c . Cannot share wife with c h i l d . S o c i a l  Partner Communicates e a s i l y with wife; shares some i n -teres ts and a c t i v i t i e s ; treats her with respect when alone and i n presence of others. Does not communi-cate e a s i l y ; seldom shares i n t e r e s t s and a c t i v i t i e s with wi fe . Communicates very l i t t l e ; does not share a c t i v -i t i e s with wife; be-l i t t l e s her when alone and i n presence of others . Provider Provides we l l f or the f a m i l y ' s economic needs beyond the subs is -tence l e v e l . Meets the basic economic require-ments of the fami ly . Does not meet basic economic needs of fami ly . 176 Rating Scale for Measuring Performance i n Father Role Role C r i t e r i a S o c i a l Funct ioning Not Impaired Moderately-Impaired Severely Impaired Source of  Emotional  Support  and Guidance Shows a f f e c t i o n and understanding. Acts as counsel lor and encourages c h i l d with school and other i n t e r e s t s su i tab le to age and sex. Can place c h i l d ' s needs before h i s own. Provides a good pattern of masculine behaviour. Shows l i t t l e a f f e c t i o n or under-standing. Spends l i t t l e time with c h i l d and does not help him develop s p e c i a l i n t e r e s t s . Some competit ion with wife over c h i l d . Resents c h i l d ; i s h o s t i l e , harsh , r e -s t r i c t i v e , competes with c h i l d i n r e l a -t i o n to wi fe . gourcg of Ins truc-t i o n and D i s c i p l i n e Provides consistent d i s c i p l i n e ; i s f i r m but k i n d l y . Inconsistent i n deal ing with c h i l d , or gives i n too much and i s general ly i n -e f f e c t u a l or i s too severe. Some c o n f l i c t with wife over au thor i ty . Takes no respons i -b i l i t y f o r c h i l d ' s i n s t r u c t i o n or d i s c i p -l i n e ; or i s over ly harsh , and p u n i t i v e , or unable to impose l i m i t s . Model for S o c i a l Behaviour Respected member of community with good community r e l a t i o n -sh ips . Disp lays some s o c i a l l y unaccept-able behaviour. Has few fr i ends or community i n t e r e s t s . Displays a n t i - s o c i a l behaviour, withdrawn from soc ie ty , has no fr i ends or commun-i t y r e l a -t ionsh ips . 177 Rating Scale for Measuring Performance i n Wife Role Role Criteria Social Functioning Not Impaired Moderately Impaired Severely Impaired Source of  Emotional Support Gives husband affection and encouragement. Shows concern for his needs, physical and emotional. Has selected a husband with good masculine identification and accepts his more dominant role. Expresses l i t t l e affection for husband and gives l i t t l e encourage-ment. Not much ab i l i t y to per-ceive husband's needs and no a b i l i t y to put them before her own. Struggles with him for authority or i s overly dependent. Expresses no affection, under-mines husband's confidence. Either overly dependent or con-tr o l l i n g and domineering. Without a b i l i t y to perceive needs of her husband. Competes with him for children's affection. Social  Partner Communicates easily with husband; enjoys his company and shows pride in his social accomplishments Performs re-quired social tasks, such as entertaining with goodwill. Does not communi-cate easily; sel-dom goes out with husband; express-es anxiety about his or her social performance; resists social in-volvements. Communicates very l i t t l e ; does not go out with hus-band or entertain. Nags, and be-l i t t l e s him i n presence of others. Homemaker Keeps home mod-erately clean and attractive. Usually limits expenses to budgeted amount; prepares ade-quate meals; keeps family's clothing presentable. Has extremely high standards or shows l i t t l e interest i n household tasks, and frequently neglects them. Requires consid-erable assist-ance from others. Shows l i t t l e financial re-sponsibility. Conditions i n home are often chaotic. Wife openly resents household tasks, husband and children are often l e f t to fend for them-selves. 178 Rating Scale for Measuring Performance i n Mother Role Role Criteria Social Functioning Not Impaired Moderately-Impaired Severely Impaired Source of Maternal Love Has given con-sistent love and warmth to child since birth. Has marked ambi-valent feelings toward child; i s inconsistent, overly anxious, or apathetic, Does not give any warmth or love; over-ly harsh or overly i n -dulgent. Source of  Emotional Support Encourages child to develop own individuality; guides him through develop-mental phases; encourages extra-familial a c t i v i -t i e s . Shows l i t t l e under-standing of child's emotional needs; overcontrolling or indifferent. Strives to hold child as undiff-erentiated part of self; does not allow child self-expression, keeps child dependent or forces i n -dependence. Provider Phys-lcal  Care Provides adequate food; i s interest ed i n child's health and appear-Provides i n d i f f e r -ently for physical needs; child may have to fend for ance; and provides himself, or over-for these as well as circumstances permit. anxious about child's health and appearance Neglects child's physical needs; does not provide adequate food, clothing or care. 179 Rating Scale for Measuring Performance i n Student Role Social Functioning Role Criteria Not Impaired Moderately Impaired Severely . Impaired < Relation-ship with Teacher Likes and respects teacher; feels secure; neither overly timid nor overly aggressive Insecure and anxious; con-forming; some acting-out i n times of stress Overly depend-ent on teacher; requires step-by- step i n -struction; demands constant attention; antagonistic; unmanageable. Academic Progress Rates average or above average i n class; keeps up with school work. Rates below average but passes; f r e -quently does not complete school work or homework; un-tidy. Cannot compete with children in regular class; i s re-peating year or has been placed i n special class. Relation-ship . , with, ottoer Students Friendly, coopera-tive, secure Over-timid or aggressive; does not play well i n group. Antagonistic, jealous; hits or annoys other children; or i s very with-drawn. 180 Rating Scale f or Measuring Performance i n S i b l i n g Role Role S o c i a l Funct ioning C r i t e r i a Not Impaired Moderately Impaired Severely Impaired A b i l i t y to Mainta in , and Allow S ib l ing , to Maintain In-d i v i d u a l i t y Occas ional ly dom-ineer ing or domin-eered by s i b l i n g , but maintains own i n d i v i d u a l i t y and allows s i b l i n g to maintain h i s . i ... I I . Has tendency to c o n t r o l and dom-i n a t e . Or be c o n t r o l l e d and dominated, but not c o n s i s t e n t l y . Cons i s t en t ly contro l s and dominates s i b l i n g . Or i s dependent upon s i b l i n g . A b i l i t y %Q E s t a b l i s h Pos i t ive R e l a t i o n -ship with Sibling Involved i n some bicker ing and argu-ing but can share toys and play; shares some con-s i d e r a t i o n f o r s i b l i n g . Expresses h o s t i l -i t y through teas ing; or quarrelsome be-haviour; but can cooperate. Extreme h o s t i l i t y and jealousy, shown by cont inua l f i g h t i n g and arguing , or expressed by excessive show of a f f e c t i o n . A b i l i t y to E s t a b l i s h His Place In Family Has integrated i n t o family with r e l a t i o n to other c h i l d r e n ; f e e l s reasonably secure. Confused, insecure; f e e l s he gets l e s s than h i s share of a f f e c t i o n and mater ia l goods. Fee l s l e f t out , unwanted, re jec ted i n favour of s i b l i n g ; i s unable to e s t a b l i s h a place f o r himsel f i n the f a m i l y . 181 Rating Scale f o r Measuring Performance i n Son or Daughter Role Role C r i t e r i a S o c i a l Funct ioning Not Impaired Moderately Impaired Severely Impaired Mervtal Development Average or high-er i n t e l l i g e n c e Border l ine to du l l -normal i n t e l l i g e n c e Mental ly d e f i c i e n t Phys ica l  Development Good hea l th: normal develop-ment with no c r i p p l i n g d i s -eases or p h y s i -c a l handicaps and few i l l n e s s -es. More frequent i l l n e s s e s , c o l d s , i n f e c -t ions , sk in d i s o r d e r s , minor handi -caps, over-weight to excess. Under-developed; s i c k l y ; requ ir ing frequent medical care and treatment, Serious phys i ca l handicaps. Emotional  Development Loving, happy, secure, with growing accept-ance of own i d e n t i t y . Success fu l ly mastered developmental phases to date, Anxious, i n -secure, with some nervous mannerisms or act ing-out; Neurotic t r a i t s , phobias or compul-s ive behaviour. Res i s t s growing up, r e l i n q u i s h i n g i n -s t e a l i n g , ly ing , f a n t i l e r e l a t i o n -surface host i l - t ship with mother, i t y . an tagon i s t i c , r e -gress ion to e a r l i e r developmental stage, Sexual  Development Has good concep-t i o n of own sexual i d e n t i t y . Confused about sexual i d e n t i t y ; ex-periencing d i f f i c u l t y i d e n t i f y i n g with parent of same sex. Moving toward ident i -f i c a t i o n with opposite sex. S p c j a l  Development Outgoing and f r i e n d l y , r e -la tes to c h i l d -ren and adul t s . R e l a t i v e l y i n -dependent. Can handle new ex-periences. Timid or overly aggress-i v e ; has few playmates. Withdrawn from s o c i a l r e l a t i o n s h i p s ; r e l a t -es i n h o s t i l e -dependent way to adults ; plays with younger c h i l d r e n . APPENDIX C Measurement of Role Performance Roles Case I Case 11 Case .III COMMUNITY MEMBER extensive severe -EMPLOYEE not impaired extensive -HUSBAND extensive severe -FATHER extensive severe -COMMUNITY MEMBER extensive extensive ? EMPLOYEE not performing not performing not impaired WIFE moderate moderate not performing MOTHER extensive moderate moderate PEER extensive extensive ? STUDENT extensive severe moderate SIBLING severe extensive moderate SON OR DAUGHTER moderate extensive extensive 183 Measurement of Role Performance Roles Case IV Case y Case VI COMMUNITY MEMBER ? ? severe EMPLOYEE severe severe extensive HUSBAND extensive extensive extensive EITHER moderate extensive extensive COMMUNITY MEMBER ? ? not impaired EMPLOYEE not performing not performing not perform-ing WIFE moderate moderate extensive MOTHER extensive moderate moderate PEER ? moderate extensive STUDENT not performing extensive moderate SIBLING moderate ? extensive SON OR DAUGHTER moderate moderate extensive I8if Measurement of Role Performance Roles Case VII Case VIII Case ix COMMUNITY MEMBER ? severe ? EMPLOYEE slight severe not impaired HUSBAND slight not performing slight FATHER moderate extensive slight COMMUNITY MEMBER extensive severe moderate EMPLOYEE not performing ? not perform-ing WIFE moderate not performing slight MOTHER extensive moderate extensive PEER extensive moderate extensive STUDENT extensive extensive severe SIBLING ? moderate moderate SON OR DAUGHTER moderate moderate extensive 185 Measurement of Role Performance Roles Case X Case XI Case XII COMMUNITY MEMBER ? severe ? EMPLOYEE not impaired severe slight HUSBAND slight extensive extensive FATHER moderate extensive extensive COMMUNITY MEMBER ? severe severe EMPLOYEE not performing not performing not perform-ing WIFE moderate extensive moderate MOTHER extensive extensive moderate PEER moderate severe severe STUDENT moderate extensive extensive SIBLING extensive extensive extensive SON OR DAUGHTER moderate moderate moderate 186 INTRODUCTION "P s y c h i a t r i c h i s t o r y taking i s not merely a process of c o l l e c t i n g data. I t 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 r e f e r r o r submits i n h i s attempt to convey h i s understanding of the c h i l d , h i s family, and t h e i r problem. I t i s an organized record of the story which the family pours out to one who, having offered to help, l i s t e n s i n a warm and encouraging manner. From t h i s ' t h r i l l i n g experience' comes the family's w i l l i n g n e s s to use the resources of the Children's C l i n i c . The i n t r i n s i c value of a written case h i s t o r y i s determined neither by i t s volume nor by the mass of d e t a i l which i t contains, but by i t s o r i e n t i n g function 1. 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 c h i l d , his family,and his community. The attached a o c i a l - p s y c h i a t r i c h i s t o r y outline i s a suggested means of organizing and focusing data. For the novice i t i s an instrument i n le a r n i n g of what type of f a c t s to be aware, and f o r the experienced person i t simply serves to suggest the four broad areas of i n t e r e s t basic to a p s y c h i a t r i c d i a g n o s i s — t h e problem, family background, personal h i s t o r y , and the r e f e r r o r ' s evaluation and plan. The novice may lean upon t h i s outline as a guide to content, but never as a questionnaire or as a means of interviewing. These four headings should follow i n t h i s sequence, providing a u n i v e r s a l 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'; t h i s i s the textbook i n t h i s f i e l d of medicine. 187 SOCIAL HISTORY OUTLINE A guide to preparation of Social Histories for the Children's Clinic of the Mental Health Centre. DATE WRITTEN: DATE OF EXAMINATION: NAME: BIRTHDATE: STATUS: (Ward, non-ward, etc.) PARENTS: (FATHER) BIRTHDATE: (MOTHER) BIRTHDATE: (MAIDEN NAME) S.S. INDEX: TELEPHONE: ADDRESS: SOURCE OF REFERRAL: (By whom and how) PROBLEM: ( l ) As stated and seen by parents, 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 f e e l 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 Cl i n i c at this time. What specific help i s desired by social worker/public health nurse. DATE OF PREVIOUS EXAMINATION AT CHILDREN'S CLINIC (formerly Child Guidance C l i n i c ) , P.M.H., ETC. (Child or relatives). FAMILY HISTORY HOME SETTING: Pertinent and brief descriptive material of present home setting — economic and community status; housing; persons i n home. FATHER: ( l ) Identifying information — name; present age; place of birth; religion. (2) Social and cultural background — others i n family, ages; 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 i n family. Father's attitude and contribution with regard to problem(s); How does he handle i t ? 108 FAMILY HISTORYi (cont'd) (4.) Paternal 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 ADJUSTMENTS When, where and how did parents meet? Courtship; sexual adjustment. STEP-PARENTS OR FOSTER HOMES: 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-personal relationships? PERSONAL HISTORY DEVELOPMENTAL FACTS: Date, place of birth: Age weaned: Bladder control at: Toilet training began: Bowel control at: Teethed at: Walked at: Talked at (words): (sentence formation): 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 d i f f i c u l t i e s . Food fads or fussiness. Indigestion or any indication of gastro-intestinal disorder. (2) Elimination: Method and attitudes i n training child. D i f f i c u l t i e s . 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 i n sexual information. Any incidents of exhibitionism. Sex play. Masturbation or intercourse (describe, including age and frequency, of such incidents). Extent of sexual knowledge. From whom obtained. Evidence of development. 1 8 9 PERSONAL HISTORY (cont'd): Age of puberty. Attitude toward i t . If menses established i s i t regular? Painful? Has someone discussed puberty and sexual role with child? Any indication of abnormal sexual behaviour? (A) Physical development: Has physical growth been normal? Give incidents of il l n e s s , disease (ages) sequelae (disability, etc.) Reactions of child and parents to serious illnesses. D i s a b i l i t i e s . Operations and preparation of child for these (age). Child's attitude to and estimate of present health. Any over-compensation or over-concern. PERSONALITY AND APPEARANCE: Physical description — any indications of nervous habits; fears; disturbances of sleep; recurrent or significant dreams. General picture of the child's outstanding relationships and how he (she) uses these. How does he (she) handle feelings and need such as anger, affection, dependency i n relation to his (her) closest relationships. Attitudes to school, teachers, people i n authority. Interest and Recreation; adjustment to social groups, employment, particular friends of both sexes. Ambitions and goals. Estimate of child's insight, intelligence, humour. SCHOOL RECORD: Grade and teacher's report. Bureau of Measurements record i f i n Vancouver. EVALUATION AND PLAN Social worker's/public health nurse's evaluation of case from work done by the presenting agency. Evaluation of strengths and weaknesses in child, parents, and parent-child relationship. What has been done? How frequent are the contacts? How strong i s the worker-child relation? What methods have been tried i n working with child and parent(s)? What has been tried by family members i n dealing with problems? How successful? What possible resources are there i n family or community to help meet child's needs? What are worker1s/nurse's suggestions for carrying on from the point? Questions around which social worker/public health nurse would like discussion. ALL HISTORIES SHOULD BE SIGNED BY THE SOCIAL WORKER OR PUBLIC HEALTH NURSE AND FOUR  COPIES SUBMITTED TO THIS CLINIC. APPENDIX E BIBLIOGRAPHY A. General Books Ackerman, Nathan W. The Psycho-dynamics of Family L i f e . Basic Books, I n c . , New York , 1958. A l l e n , Freder i ck H. Psychotherapy with C h i l d r e n . W.W. Norton and Company, I n c . , New York, 19*+2. E i s e n s t e i n , V i c t o r W. Neurotic Interact ion i n Marriage . Basic Books, I n c . , New York , 1956. Pol lock , Otto . Integrat ing S o c i o l o g i c a l and Psychoanalytic  Concepts. R u s s e l l Sage Foundation, New York, 1956. Unpublished Papers McCann, Charles W. "Role Theory and Profes s iona l Responsi-b i l i t y J An A p p l i c a t i o n of the Theories of Role and Stress to S o c i a l Casework P r a c t i c e . " School of S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia, 1961. B. Spec i f i c Books Bernard, J e s s i e . S o c i a l Problems at Midcentury. The Dryden Press , New York, 1957. Boehm, Werner W. Objectives for the S o c i a l Work Curriculum  of the F u t u r e . ( V o l . I , S o c i a l Work Curriculum Study) , Counc i l on S o c i a l Work Educat ion , New York, 1959. . The S o c i a l Casework Method i n S o c i a l Work Educat ion . ( V o l . X , S o c i a l Work Curriculum Study) , Counc i l on S o c i a l Work Educat ion , New York, 1959. Perlman, Helen H . S o c i a l Casework. The U n i v e r s i t y of Chicago Press , Chicago, 1957. Richmond, Mary E . What i s S o c i a l Casework? R u s s e l l Sage Foundation, New York , 1922. 191 AffUcle,s Aber le , David F . and Naegle, Kaspar D. "Middle-Class Fathers ' Occupational Role and Att i tudes Toward C h i l d r e n , " A Modern J^rpdMQ.UQfl tQ, tfte Fami ly , ed. Norman W. B e l l and E z r a F . Voge l , The Free Press of Glencoe, 111., i960. Beck, Dorothy Fahs. "Research Relevant to Casework Treatment of C h i l d r e n . " S o c i a l Casework, F e b . - M a r . , 1958. Bowers, Swithun. "The Future of S o c i a l Work." The S o c i a l  Worker, January, i960. Hamilton, Gordon. "A Theory of Persona l i ty : Freud's C o n t r i -bution to S o c i a l Work." Ego Psychology and Dynamic Case-work, ed. Howard J . Parad, Family Service Assoc ia t ion of America, New York, 1958. H o l l i s , F lorence . "Contemporary Issues for Caseworkers." Smith Col lege Studies i n S o c i a l Work, Feb., i960. Perlman, Helen H . "The S o c i a l Casework Method i n S o c i a l Work Educat ion: A Review." S o c i a l Service Review, December, 1959. Regensburg, Jeanette. "The Curriculum Study: Implicat ions f or the Pract ice of S o c i a l Casework." Social, Casework, January, i960. S p i e g e l . John P. "The Reso lut ion of Role C o n f l i c t With in the F a m i l y . " A Modern Introduct ion to the Fami ly , ed. Norman W. B e l l and Ezra F . Voge l , The Free Press of Glencoe, 111., I960. S t e i n , Herman D. "The Concept of the S o c i a l Environment i n the S o c i a l Work P r a c t i c e . " Smith Col lege Studies i n S o c i a l  Work, June, i960. • "Some S o c i o l o g i c a l Concepts i n Casework P r a c t i c e . " Smith Col lege Studies i n S o c i a l Work, February, Z e l d i t c h , M o r r i s . "Role D i f f e r e n t i a t i o n i n the Nuclear Fami ly : A Comparative Study." A Modern Introduct ion to  the Fami ly , ed. Norman W. B e l l and Ezra F . V o g e l , The Free Press of Glencoe, 111., i960. Theses Morton, Betty Marie . The Psychodynamlcs and Treatment of the  Male Partner i n M a r i t a l C o n f l i c t Cases. Master of S o c i a l Work Thes i s , U n i v e r s i t y of B r i t i s h Columbia, 1957. 

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