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Resistance of the adolescent to casework services : relationship of emancipatory efforts and psychosexual… Beck, Dorothy Joan 1954

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RESISTANCE OP THE ADOLESCENT TO.CASEWORK SERVICES Relationship of Emancipatory E f f o r t s and Psychosexual C o n f l i c t s of Adolescence to Resistance. Shown i n Treatment at the Child Guidance C l i n i c , Vancouver. by DOROTHY JOAN BECK Thesis Submitted i n P a r t i a l F u l f i l l m e n t of the Requirements for the Degree of MASTER <$F SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1 9 5 4 The University of B r i t i s h Columbia iv ABSTRACT This study of resistance of the adolescent to case-work services was undertaken i n an e f f o r t to determine i f any rel a t i o n s h i p existed between the resistance shown and the emancipatory e f f o r t s and psychosexual c o n f l i c t s of t h i s age. Thirty adolescents shwing resistance throughout th e i r casework contact at the Child Guidance C l i n i c of Vancouver were used i n this connection. These t h i r t y adolescents showed four main patterns of resistance. The majority of 50%, showed progressive resistance over their contact with the agency. The next largest group of 20% showed swings In resistance; generally manifesting more resistance i n i t i a l l y and terminally than i n the exploratory period of casework. The t h i r d group of 16 2/5% showed consistent p a r t i c i p a t i o n or resistance through-out their c l i n i c contact and evidenced l i t t l e movement during th i s time. The l a s t group of 13 l/z%, were decreasingly r e s i s t a n t as casework proceeded and appeared to be the group who externalized and worked through their i n i t i a l resistance most successfully. Of the t h i r t y adolescents who were diagnosed as i n need of intensive casework treatment; only four continued treatment at the c l i n i c . Three other youngsters were re-f e r r ed elsewhere for help; and 23 ceased treatment of any kind as a d i r e c t r e s u l t of their resistance. This r e s i s -tance seemed intimately connected with the adolescent stage of development. Emancipatory e f f o r t s , interfered with treat-ment i n 60% of the cases. Oedipal attachments to parents complicated the treatment rel a t i o n s h i p i n 30$ of the cases; and i n a b i l i t y to r e l a t e precluded use of treatment i n 10% of this group. The fact that these adolescents a l l came from homes in which parent-child d i f f i c u l t i e s predominated meant that the normal solution of adolescent problems were hindered. It leads us to believe that resistance to casework i s an almost inevitable consequence of such d i s t o r t e d family settings. To cope with such resistance implies that we must f i r s t of a l l be a l e r t to resistances, which may be overt or latent, in our f i r s t contact with the adolescent c l i e n t . Use of the. peer group i n treatment settings needs to be explored further. Increased integration of community resources i s v i t a l i f f u l l use i s to be made of exi s t i n g sources of help by the adolescent i n need of assistance. Also, new resources; such as a residen-t i a l treatment center; pro f e s s i o n a l l y led parent education groups, etc., must be established to reach the d i f f i c u l t group of c l i e n t s . More attention must be given, also, to the case-worker dealing with these r e s i s t a n t c l i e n t s ; i f her own anxiety i n the face of the c l i e n t ' s withdrawal i s not to increase such tendencies i n the adolescent. A follow-up study of the results of casework help to such r e s i s t a n t adolescents needs to be done i f we are to know the value of spending our time with these d i f f i c u l t c l i e n t s . V ACKNOWLEDGEMENTS The writer wishes to express her gratitude to a l l those persons who contributed, so generously, of their time and knowledge to this thesis. E s p e c i a l l y to Miss Muriel C u n l i f f e , of the Child Guidance C l i n i c and School of S o c i a l Work, who inspired the writer's f i r s t interest i n this subject of resistance i n the adolescent group. Her contin-ued interest and guidance during the writing of thi s thesis, was of invaluable help. The writer would also l i k e to thank Mrs. E s t e l l e Chave, of the Chi l d Guidance C l i n i c , hot only for her assistance i n the compilation of cases used in this study, and her active interest i n and c r i t i c i s m of the material as i t was compiled; but also for her ever present inte r e s t and encouragement to the writer. To Dr. Leonard Marsh of the School of Social Work, is due a deep apprecia-t i o n for his patience, stimulation and encouragement which was present from the inception of this, thesis to i t s completion. The writer i s also indebted to the entire s t a f f and administration of the Child Guidance C l i n i c , who were so cooperative and help f u l during the long and incon-venient process of case analysis. Special thanks Is due those caseworkers who so generously explored t h e i r own caseloads for r e s i s t i n g adolescents to be used i n this study. . Also to Dr. Gaston E. Blom, Associate Director of the Child Psychiatry Unit, Massachusetts General Hospital, Boston, Massachusetts, special thanks for his kind c o n t r i -bution <fi his own findings in dealing with a res i s t a n t adolescent boy. TABLE OP CONTENTS Chapter 1. Resistance and the Adolescent Page The Vancouver Child Guidance C l i n i c . Res-istance. Notes on adolescence. Casework and the adolescent. The present study 1 Chapter 2* Manifestation of Resistance by Thirty  Adolescents i n Child Guidance C l i n i c Treatment Explanation of schedules. Composition of studied group. Source of r e f e r r a l . Family Set-ti n g . Disposition of cases. Patterns of Resis-tance: progressive resistance; swings i n r e s i s -tance; consistent resistance; decreasing resistance. Resume. . . . 30 Chapter 3. Underlying Resistance - What? Causes underlying resistance. Resistance and presenting problem compared. I n a b i l i t y to Relate. I n a b i l i t y to relate and emancipation. Emancipation. Oedipal attachment. Emancipation and Oedipal attachment. Observations 63 Chapter 4. Working with Resistance Restatement of Focus. Findings of the present study. The caseworker. Intake and over-coming resistances. Group approach at intake. Group approach In treatment. Diagnostic understanding of resistance. Interpretation and resistance. The community and the adolescent; treatment and preventa-tive services. Conclusion 94 Appendices: A. Proposed' Outline for Studying Case Material. 122 . B. Course of Resistance i n Individual Adolescents by Pattern 124 C. Presenting Problem and C l i n i c a l Diagnosis of Individual Adolescents by Cause of Resistance. 126 D. Bibliography. 131 TABLES AND CHARTS IN THE TEXT (a) Tables Fi g . 1. Source of r e f e r r a l and i n i t i a l resistance. . 36 Fi g . 2. Stimulus and i n i t i a l resistance. 37 i l l (b) Charts F i g . 3. Family setting 39 Fi g . 4. Disposition of cases 44 F i g . 5. I n i t i a l manifestation of resistance 47 F i g . 6. Manifestation of resistance: four main patterns 48 F i g . 7. Frequency of underlying reasons for resistance. 64 F i g . 8. Relationship of cause of resistance to presenting problem 66 v i RESISTANCE OF THE ADOLESCENT TO CASEWORK SERVICES Relationship of Emancipatory E f f o r t s and Psychosexual Conficts of Adolescence to Resistance Shown i n Treatment at the Child Guidance C l i n i c , Vancouver I RESISTANCE AND THE ADOLESCENT The adolescent has long heen recognized for his resistance to casework treatment. Many professional publi-cations about the adolescent have reasserted the fact that he Is not an easy client to deal with. This study proposes to examine thirty adolescents resisting casework treatment at the Vancouver Child Guidance Clinic in an effort to ascertain i f the resistance manifested by this group is connected with the emancipatory efforts and psychosexual conflicts of this age. The Vancouver Child Guidance Clinic The Vancouver Child Guidance Clinic is a mental health service for children. The c l i n i c defines itself-*- as a community agency in which specialized professions combine their knowledge and attempt to employ the resources of the community to meet the problems of children who are poorly adjusted to their environment and have unsatisfied inner needs. This maladjustment may show up in undesirable habits or personality traits; unacceptable behaviour; or inability.to cope with social or scholastic expectations. Children seen include those who are the responsibility of child welfare agencies, when these agencies are concerned about the emotional conse-quences of placement because of dependency, broken homes and illegitimacy. The services of the Child Guidance Clinic are carried out by a team consisting of psychiatrist, psychiatric This brief description of cl i n i c services is taken from the'instructions of the Child Guidance Clinic to referring agencies. 2 social workers, psychologists and public health nurses. There are five main types of services rendered to the child, his parents and other social agencies. The diagnostic $• service includes a f u l l c l i n i c a l examination of the child f o l -lowed by a conference attended by the c l i n i c team and any referring person Involved. In the conference the c l i n i c a l diagnosis and recommendations for treatment are given and discussed in terms of the total needs of the patient and the resources of the agency and community, A consultative service is one in which a conference is requested with the psychiatrist and other members of the clinfc team when this conference is not immediately preceded by clinic al examination of the patient. The patient discussed may never have been seen by the c l i n i c , or he may have been examined on a previous occasion. The worker requesting such a service prepares a history or summary containing a l l pertinent information regarding the client so that the case may be discussed by well informed team members. When a case is presented at the c l i n i c and i t is the decision of the conference that intensive psychiatric treatment or casework should be done by c l i n i c a l personnel while the referring worker is also carrying on an agency service, this case is known as a co-operative case. The Child Guidance Clinb Is then the major agency and takes the responsibility for forwarding information to the referring agency and consulting frequently with them in regard to their joint activity. A c l i n i c treatment case is one in which the cl i n i c team takes f u l l responsibility for treatment services. Such cases 3 are r e f e r r e d d i r e c t l y to the c l i n i c hy parents, schools, private physicians etc., and are not active i n another agency. The f i f t h service i s that of re-examination and i n -volves the same procedure as the diagnostic service. This may occur i n any of the above mentioned eases. This study i s concerned only with co-operative and c l i n i c treatment cases, which i n some instances, may have been re-examined i n the course of their contact with the agency. The majority of work at the c l i n i c i s concerned with the pre-adolescent group of children with at £ast average i n t e l l i g e n c e . The sources of r e f e r r a l are varied. In the 1952-53 Annual Report of the Child Guidance C l i n i c , i t was shown that 43.11$ of i t s r e f e r r a l s were from s o c i a l agencies; 18.46$ from medical and health agencies; 13.78$ from schools (including the Boy's and G i r l ' s I n d u s t r i a l Schools, the Deaf and Blind School, as well as public schools); 5.12$ from the Juvenile Court; 3.0-9$ from the adult courts; 6.18$ from private physicians; 10.17$ from parents, r e l a t i v e s , c l i e n t s or friends; and .09$ from other sources. Many of these referr e d persons are seen on a diagnostic or consultative basis only and do not proceed with treatment by the c l i n i c s t a f f . The c l i e n t who comes to the c l i n i c under his own auspices i s known as a "private case". The intake department of the c l i n i c assigns a caseworker to carry through to the diagnostic conference with this c l i e n t , at which time he w i l l be transferred to a continuing worker or referred to a more appropriate agency. The intake worker'takes the major responsi-b i l i t y during her contact with the c l i e n t , to prepare the patient to u t i l i z e c l i n i c help and to prepare a pertinent diagnostic history concerning his. s i t u a t i o n . When the worker has assessed the appropriateness of the c l i n i c services i n r e l a t i o n to the c l i e n t ' s problem and the a b i l i t y of the c l i e n t to use these services, she brings this information to the intake conference. At this conference, a f u l l team w i l l discuss the s i t u a t i o n presented by the caseworker and decide whether or not the agency can be of service to the patient concerned. Once accepted for service, a permanent psychiatric team i s assigned and arrange-ments are made by the team members to see the c l i e n t and his family i n order to compile the information they need to make a v a l i d diagnostic int e r p r e t a t i o n of the problem, according to their own d i s c i p l i n e . When the c h i l d and his parents have been so examined by a l l members of the team, they again convene at the diagnostic conference to pool th e i r thinking about the diagnosis and treatment plan for the c h i l d and his family. Frequently, the treatment plan w i l l involve casework for both the c h i l d and his parents. Resistance In casework, s k i l l Is employed i n mobilizing the c l i e n t ' s strengths for an active p a r t i c i p a t i n g role i n the solution of his problem^" be they predominantly s i t u a t i o n a l , emotional, or s o c i a l . In the casework f i e l d there ks been a s h i f t in.focus from that of giving only a p r a c t i c a l service, to that of involving the c l i e n t i n using the p r a c t i c a l service or treatment. One person w i l l need more help i n involving himself i n the solution of his d i f f i c u l t i e s than another. Through l i v i n g with his problem, the c l i e n t erects defenses 5 to protect his ego from harm, c r i t i c i s m or anxiety. "Resistance" to casework help^describes the c l i e n t ' s use of defenses to $ avoid y i e l d i n g himself to the treatrre nt s i t u a t i o n . "Involved here may be reluctance to look at his problems as 'mental'; or, more b a s i c a l l y , reluctance to consider that changes i n himself are needed and that changes can come about only through his active p a r t i c i p a t i o n i n the treatment process."1 "The c h i l d r e s i s t s change; i . e . he i s disturbed by anything that w i l l deprive him of his*" accustomed modes of g r a t i f i c a t i o n or anything he thinks w i l l deprive him of them. He reacts to t h i s inner f e e l i n g of discomfort by f e e l i n g antagonistic and annoyed with the source of his deprivation."^ Fear of change i s something basic to man. He feels insecure i n the face of something new. Habit and past experience are representative of security, for he knows them. "A person i s motivated to change because, of the hope of s a t i s f a c t i o n . • . . i f a person i s i n any r e a l sense to change his attitudes or his l i f e d i r e c t i o n , t h i s can only be achieved by something more than a s o l e l y i n t e l l e c t u a l stimulus . . . . So far as we know i t i s only be means of a deeply f e l t experience i n r e l a t i o n s h i p that treatment can af f e c t a person's attitudes towards himself and his fellows. "The patient's decision to see a therapist i s no easy one The pressures which force him to take this step must be f a i r l y urgent ones. He has essential barriers to J-Anderson, D.M.; Keisl e r , F.; "Helping Toward Help: The Intake Interview", Social Casework, February, 1954. 2 E n g l i s h , O.S.(M.D.); Pearson, G.H.J.(M.D.); Emotional Problems of Living, 1945, p. 105 ^Hamilton, G.; Theory and Practice of Sochi Casework, p.26 6 overcome. The f i r s t , and probably most important of these, evidences his unwillingness to upset his own neurotic equilibrium."^ Although the person comes to a s o c i a l agency with the hope of resolving the problem which has caused him enough discomfort to warrant t h i s d r a s t i c step; -.he w i l l f e e l two ways about changing his mode of operation. Sometimes the c l i e n t w i l l want the s o c i a l worker to take over the responsi-b i l i t y of solving his d f f i c u l t l e s for. him.. The r e a l i z a t i o n that this i s not the modus operandi of the caseworker may p r e c i p i t a t e a threat to the c l i e n t . As he r e a l i z e s the task ahead involves hard work and pain on his part; and that the s o c i a l worker's role w i l l be lar g e l y an enabling one; he may f e e l that the "cure" i s worse than the "disease". "Unless there i s an understanding of the defenses that are c a l l e d into use at the point when a person i s about to involve himself . . . i n disturbing s e l f - s c r u t i n y , progress i s greatly impeded." 2 I n i t i a l resistance may be manifested by the c l i e n t ' s f a i l u r e to keep regular appointments and his r e f u s a l to discuss his problem. Due to his own unreadiness for treatment or the caseworker's f a i l u r e to recognize and meet his resistance, the c l i e n t may be prone to terminate treatment early. The l a t t e r i s An indica t i o n of the c l i e n t ' s resistance against going on with the struggle of treatment. I n i t i a l resistance may be understood i n terms of the c l i e n t ' s insecurity and fear of the unknown. •Hffhi taker, C.A. (M.D.); Malone, T.P. (Ph.D.): The Roots  of Psychotherapy^ 1953, p. 70 # 2Hanfordj Jeanette, "The Place of the Family Agency i n Ma r i t a l Counseling", Social Casework, June, 1953, p. 252. 7 The c l i e n t cornea to casework with a s e l f protective attitude, expecting to he judged. The caseworker may represent a symbol of a society whose c r i t i c a l judgment he fears. As a r e s u l t , the c l i e n t tends to protect himself and he i s unable to look objectively at himself and at the cause of his malady. His i n a b i l i t y to talk about his problem may stem from personal or c u l t u r a l i n h i b i t i o n s , or both. He may be ashamed to admit, what seems to him, to be f a i l u r e to manage his own a f f a i r s . His p a r t i c u l a r problem may be c u l t u r a l l y stigmatized. Vague fears of the unknown may make the applicant hesitant and cautious about giving information. He may be f e a r f u l of the l i s t e n e r ' s reaction. f r i e n d l i n e s s of the worker i s trustworthy, and that he askso questions i n order to be of assistance. In t h i s non-judgmental atmosphere, the c l i e n t gathers strength to look at himself objectively and to reveal himself to the caseworker as he r e a l l y i s and as he sees himself, and to do what i s necessary for constructive change. "In the i n i t i a l contact, a l l . . . (c l i e n t s ) should gain some sense that a new p o t e n t i a l source of strength i s available to them i n their r elationship with the worker."""" treatment. This may be seen i n the c l i e n t ' s r e f u s a l to give necessary information or his rush of t a l k that overwhelms the worker. He may have d i f f i c u l t y i n finding time for his appointments, be c r i t i c a l and doubtful of the agency and question the worker's competency. He may deny that he has a problem, To be helped, the c l i e n t must recognize that the Resistance may be manifested spasmodically throughout iLewis. M.L.: "Th Social Casework, ives of A l c o h o l i c s f , 8 often Indicating that he does not want the worker to go too f a r . The strength of the c l i e n t ' s resistance may be guaged from the extremity of his reactions. Extreme helplessness and hopelessness i n the face of alternatives; extreme pro-j e c t i o n of d i f f i c u l t i e s or the need to change onto others; r e p e t i t i v e presentation of obstacles to inquiry or treatment; i n t e l l e c t u a l i z a t i o n and garrulus t a l k or empty terminology--a l l may be signals that resistance i s strong. Resistance which i s manifested during the course of treatment may be mobilized when the c l i e n t glimpses what i s involved i n getting his problem solved. P.H. A l l e n 1 regards "resistance", i n working with 1 children, as the way i n which individuals reveal their negative f e e l i n g s . When the negative feelings of the c l i e n t are blocked, A l l e n believes that the c l i e n t turns these feelings more and more towards the c l i n i c worker. Therefore, he contends that i t i s esse n t i a l that the c l i e n t be allowed to express his negative feelings i n whatever way he is able. P a r t i c u l a r l y at intake i s i t important that the c l i e n t be free to express his feelings about the c l i n i c and the fact that he may regard the agency as forcing upon him services he does not want. Verbal acceptance of the c l i e n t ' s resistance by the worker may help the c l i e n t move ahead. As the worker discusses the c l i e n t ' s request for help, she tries to help him see what i t is she can o f f e r . "Starting wholly on ttie c l i e n t ' s terms is •'-Allen, P . H . " C r e a t i o n and Handling of Resistance i n C l i n i c a l Practice", American Journal of Orthopsychiatry, July, 1932. r a r e l y wise, but with s l i g h t concessions the worker may move i n , and together the two may proceed." 1 In the fiourse of treatment, a counter-current i s set up i n which the c l i e n t p u l l s away from the worker and figh t s to keep his problem intact, as the s i t u -ation would not have been created had the problem hot answered some need of the c l i e n t ' s personality. "Faced., with the loss of predetermined patterns of behaviour, the patient has l i t t l e to which to retreat, being i n s u f f i c i e n t l y integrated to organize and express his affect maturely."^ When the worker meets resistance i n his c l i e n t , he must always look at the r e a l i t y factors In the interview s i t u a t i o n i t s e l f , to see i f any modification of this, i s indicated. Resistance i s less mobilized when the interviewer is sincerely interested and f r i e n d l y and explains the reasons for asking d i f f i c u l t questions; and when the interviewer does not project his own goal i n treatment onto the c l i e n t ; but lets the client set his own goal. The c l i e n t offers more i f he thinks ths worker can accept him as he i s . Resistance may occur quite apart from the interview si t u a t i o n , hovjever. When the c l i e n t ' s s e l f awareness or impulsivity threatens his personality, he w i l l erect defenses which may interfere with his involvement i n the treatment area. Or, i f the c l i e n t i s unable to express negative feelings towards his r e a l i t y s ituation, he is apt to project this onto the treatment s i t u a t i o n . For example, a parent may show negative reactions to treatment, which, when examined, may be the result of his severe r e j e c t i o n of his c h i l d , which he i s unable to express d i r e c t l y to the worker lHamilton, G., Theory and Practice of S o c i a l Casework, 1951. 2\rntaker, C.A.(M.D.); Malone, T.P. (Ph.D.): The Roots  of Psychotherapy, 1953, p. 125. 10 because he i s forever being corrected i n his statements about his c h i l d . There are two schools of thought i n casework theory and practice, namely the Functional School and the Dynamic 1 School. Townsend , as a representative of the Functional School, states that the caseworker i s only responsible for interpreting her own and the agency's role as simply as possible i n r e l a t i o n t o the c l i e n t ' s request. She contends that i n the end, the caseworker must respect the c l i e n t ' s r i g h t to make a negative, as well as a p o s i t i v e , chdce about using the services offered. She backs th i s up by saying that the problem must remain the c l i e n t ' s , and I f anything i s to be done about It the c l i e n t himself must be the one, ultimately, to do i t . She feels the worker's job i s to make thi s fact as clear to the c l i e n t as i t i s to the worker, herself. Lionel Lane, 2 representing dynamic thinking, contends that there should be a greater g&ng 6ut to the c l i e n t i n exi e f f o r t to overcome the strong resistance he feels towards accepting services; by procedures that w i l l overcome the c l i e n t ' s tendency to cut himself o f f from such needs. He believes that i n order to rbnprove situations i n which the c l i e n t prematurely withdraws from the treatment si t u a t i o n , the agency must take more r e s p o n s i b i l i t y and ask i t s e l f i f i t has done a l l i t could to help the c l i e n t reach a decision regarding his p a r t i c i p a t i o n i n casework. Lane hastens to c l a r i f y this from forcing help on •LTownsend, Gladys E., "Short Term Casework with Clients Under Stress"> Social Casework, November, 1953. 2Lane, Lionel C.,"Aggressive Approach i n Preventive Casework'with Children's Problems", Journal of Social Casework, February, 1952. 11 the c l i e n t . He points out that the c l i e n t who i s not ready to s t a r t , due to the lack of f e e l i n g that he actually needs help, actually needs a great deal more i n the way of active encour-agement; and that i t i s necessary that the worker Is clear about the help she can give i n each s p e c i f i c s i t u a t i o n i n order to help the c l i e n t understand the agency. When the c l i e n t has "been referred by some authoritative person, the worker must be patient and receptive, as well as firm as to her r i g h t to be i n the s i t u a t i o n . Resentment of authority may be a pertinent factor i n the c l i e n t ' s resistance and p a r t i c u l a r l y so with the adolescent c l i e n t , for one of his main anxieties at this time i s around authority. IS modifying this attitude, the worker must give the c l i e n t a p o s i t i v e sense of authority through close contact which treats him with respect. By exploring the c l i e n t ' s f e e l i n g about authority and the "why" of the f r i c t i o n s that have arisen, and by a recognition with the c l i e n t that he, himself, suffers most from s t r i k i n g back i n a b l i n d h o s t i l e way; the caseworker can help him decide on more appropriate ways of approaching and,getting along with authoritarian figures. Lane bases his philosophy on the principle that the c l i e n t has Impulses to r e s i s t treatment, but also a wish to Improve his s i t u a t i o n . His decision about receiving help shuld take both impulses into account. The writer supports this view and believes that resistance i s not necessarily a negative component of casework, but may well be the toe-hold for constructive treatment since often the very fact that the c l i e n t i s so mobilized to f i g h t treatment may be an i n d i c a t i o n of his a b i l i t y to p a r t i c i p a t e in the treatment process i f this energy can be caught and re-12 channeled. For those c l i e n t s who tend to run away, and seem unable to use casework help, i t i s necessary that the worker respond q u i c k l y and d e c i s i v e l y to the needs of the c l i e n t i n h i s i n i t i a l a p p l i c a t i o n f o r help. The c l i e n t must ask and r e c e i v e , where t a n g i b l e or i n t a n g i b l e help i s given, on a f e e l i n g l e v e l w i t h the worker. He e s p e c i a l l y needs a f f i r m a t i o n of the worker's i n t e r e s t and regard f o r the c l i e n t ' s worth--at onceJ The worker can c o n s o l i d a t e the w o r k e r - c l i e n t r e l a t i o n s h i p by r e a l i s t i c handling of emergency problems and by c l e a r recog-n i t i o n of the r e a l c r i s i s i n h i s a f f a i r s when he presents h i m s e l f to the agency. Help must concentrate on g e t t i n g him out of h i s present predicament so that he may be motivated to continue h i s contact. The c l i e n t may be motivated i n coming to the agency because he honestly f e e l s the agency can do something; or to impress someone that he i s doing something about h i s problem. I t i s important that a rough s o c i a l d i a g n o s i s be e s t a b l i s h e d at i n t a k e ; and that a move be taken to i n i t i a t e the agency's treatment program wi t h s p e c i a l reference to the known p e r s o n a l i t y c h a r a c t e r i s t i c s of the c l i e n t and of the pressures that brought the c l i e n t to the agency. The d i a g n o s i s of the c l i e n t at t h i s p o i n t , does not need to embody h i s e n t i r e problem and t e n t a t i v e treatment. In f a c t , the w r i t e r b e l i e v e s that to attempt such a task at thi s , p o i n t may be d e t r i m e n t a l to the c l i e n t ' s use of treatment. Instead, the assessment of the c l i e n t at t h i s p o i n t should aim towards e s t a b l i s h i n g h i s readiness to r e c e i v e help, the r e a l i t y and emotional problems most p r e s s i n g at t h i s time and the c l i e n t ' s 13 expectations of the agency. Then, the worker can help the c l i e n t see the assistance the agency can offer him and through the support and encouragement, given by the worker, the c l i e n t i s better able to move into the treatment s i t u a t i o n r e a l i s t i c a l l y . " . . . to the c l i e n t whose ego and superego structures are weak, the usual techniques of e l i c i t i n g information and of helping the c l i e n t to examine his problems and ways of solving them may not be r e l i e v i n g or reassuring. They must be sought out, helped over hurdles, and guided i n managing their pressing r e a l i t y problems." 1 Adolescence i —————————— Resistance to casework help i s not l i m i t e d to any p a r t i c u l a r age group. The dynamic reasons behind resistance are multiple and related to the p a r t i c u l a r individual's l i f e s i t u a t i o n . That the adolescent's l i f e s i t u a t i o n d i f f e r s d r a s t i c a l l y from that of the mature adult's i s obvious. Does his r e s i s t a n c e t o casework treatment r e l a t e to this p a r t i c u l a r stage i n his development? Are these patterns of resistance i n adolescents related to their relationship with parents . and their, struggle for emancipation? What c h a r a c t e r i s t i c ways of thinking may make the adolescent's resistance related to his stage of development. the Stanley G. H a l l describes/adolescent as "(one) yet i n the nest, and va i n l y attempting to f l y while i t s wings have only p i n f e a t h e r s . " 2 Adolescence i s characterized as an age of •'•Editorial notes, "Relationship Factors", Social  Casework, July, 1953. ^Garrison, Karl C , Psychology of Adolescence, New York, 1951. 14 "storm and s t r e s s " . The new conflicts i n adolescence b r i n g up the o l d unsolved s i t u a t i o n s as w e l l . The u n i v e r s a l c h a r a c t e r i s t i c of the adolescent i s that he Is always a c o n t r a d i c t i o n . There seem to be two main causes f o r t h i s c o n t r a d i c t i o n . One, i s h i s attempt to f i n d c l e a r cut answers to h i s i n t e r n a l c o n f l i c t s and problems imposed by the r e a l world. The second, i s the adolescent's attempts to l o c k but one p a r t of h i s c o n f l i c t i n order to f u l f i l l the urges the c o n t r a s t i n g p a r t of the c o n f l i c t a c t i v a t e s . The b i o l o g i c a l changes and the impact these have on h i s p s y c h o l o g i c a l e q u i l i -brium provide stimulus f o r confused behaviour. Along w i t h an Increased urgency f o r maturation and an urgency f o r sexual f u l f i l l m e n t , i s an increase i n aggressive energy w i t h which to s t r i k e out more e f f e c t i v e l y against c o n t r o l l i n g forces that s t r i v e to prevent g r a t i f i c a t i o n of h i s impulses. This increased energy to face l i f e s i t u a t i o n s w i t h more aggression i s necessary f o r the f u l f i l l m e n t of h i s i n c e n t i v e toward maturation. The adolescant i s c h a r a c t e r i s t i c a l l y s e c r e t i v e about h i m s e l f and h i s f e e l i n g s . I t i s d i f f i c u l t f o r him to v e r b a l i z e h i s f e e l i n g s ; and he f e e l s timonous about exposing himself and h i s f e e l i n g s . "He i s too aware that i n s e c u r i t y i s the root of h i s need f o r i s o l a t i o n . Hence the shyness, awkwardness, and h y p e r s e n s i t i v i t y l e s t others w i l l n o t i c e what he wants to hide; hence the r e b e l l i o u s p r i d e that he d i s p l a y s i n defending h i s new v a l u e s , which he has acquired to s a t i s f y a new ego -ideal and which he appraises as d i f f e r e n t from the o l d one, formed a f t e r the mother and/ or the father."" 1' Even here there may 1Benedek, "Therese, " P e r s o n a l i t y DevaLopment" i n Dynamic P s y c h i a t r y , 1952., p. 97. 15 i n c o n s i s t e n c y , because the adolescent can, on occasion, bare his s o u l > , t e l l i n g of h i s ambitions, f e e l i n g s of g u i l t , and h i s conscious awareness of h i s c o n f l i c t s . The c h i l d ' s conscience i s a. r e s u l t of i n c o r p o r a t i o n , i n t o h i s unconscious p s y c h o l o g i c a l s t r u c t u e , of the standards imposed by h i s parents. The c h i l d i s thereby able t o avoid the danger of r e j e c t i o n or punishment by h i s parents. This conscience i s subsequently modified by other a d u l t s , s i b l i n g s and other c h i l d r e n . In l a t e n c y , the c h i l d ' s conscience i s m o d i f i e d by h i s peer group, and t h i s i s u s u a l l y accepted by parents. Since t h i s i n f a n t i l e conscience i s a part of c h i l d -hood, i t becomes a b a r r i e r against maturation f o r the adolescoat, and he therefore must r e b e l against i t . I t i s t h i s r e b e l l i o n that i s manifested i n the f l a u n t i n g of new freedom i n the adolescent. He i s , i n t h i s way, seeking a symbol of conscious r e b e l l i o n against h i s parents. Since heterosexual i t y i s f o r -bidden by the i n f a n t i l e conscience, the adolescent's sexual f e e l i n g s must be f r e e d Before he can achieve heterosexual m a t u r i t y . C e r t a i n a c t i v i t i e s denied the c h i l d become permis-sable to the adolescent, and he must modify h i s standards a c c o r d i n g l y . This r e b e l l i o n i s f r i g h t e n i n g to the adolescent, however, since h i s o l d cons cience gave him a sense of ease \ | i t h himself. As h i s anxiety mounts, he needs to strengthen h i s o l d defenses and he c o n s c i o u s l y becomes more a l e r t and r i g i d . A c t i n g out i n defiance of h i s conscience, r e s u l t s In overwhelming g u i l t r e a c t i o n s when h i s conscience i s again i n c o n t r o l . His conscience does not succeed i n p r o h i b i t i n g behaviour, but once 16 the forbidden act is committed, It uses a l l force to punish. The adolescent's parents are symbols of his conscience, and therefore part of his struggle against his infantile conscience is externalized to his parents. He is in a similar inconsistent relationship to parental controls. He resents authority and shows contempt for his parents' beliefs and pattern of living; while at the same time he seeks controls and slavishly follows the family mores. The adolescent places great value on parental restrictions because they assure him of external restraint against unfettered freedom and punishment i f he should overstep the rules. These restrictions give him an "out" from gang activities undesirable to the adolescent, either consciously or uneonsciously. These rules shift responsibility from himself to the family when he is fearful of his own capacity. The adolescent conscience also undergoes modification by his peer group. I'he average social group wishes to be accepted by the social structure and therefore does not abandon the more important prohibitions the parents imposed. Acceptance by the child of this group-formulated pattern of behaviour, gives the child a sense of security In the world of classmates and friends. This security with his peers is of extreme significance at adolescence. Panic resulting from unresolved conflicts is handled, In part, by the individual's seeking a haven in the security his peer group offers. The adolescent turns to the peer group for answers and support. He can discuss his mixed feelings and can find solace in the identical sufferings of others. 17 A l t h o u g h t h i s p a p e r d e a l s w i t h c a s e w o r k m e t h o d s ; i n a n y d i s c u s s i o n o f t h e a d o l e s c e n t , g r o u p w o r k m e t h o d s m u s t a l s o be m e n t i o n e d . The c o n s t r u c t i v e I n f l u e n c e o f t h e g r o u p o n t h e a d o l e s c e n t i s m o r e t h a n a n y one a d u l t c a n s u p p l y . The a d o l e s c e n t c a n u n d e r s t a n d , a c c e p t a n d a s s i m i l a t e t h e t e a c h i n g s o f h i s own p e e r s m o r e e a s i l y t h a n t h a t o f a d u l t s . H i s r e l a t i o n s h i p t o h i s p e e r g r o u p i s l e s s e m o t i o n a l l y c h a r g e d t h a n h i s r e l a t i o n s h i p w i t h o l d e r p e o p l e . The p e e r g r o u p o f f e r s l i m i t a t i o n s , f r e e d o m a n d s t a n d a r d s i n a f o r m a c c e p t a b l e t o t h e a d o l e s c e n t . H e w i l l s t r i v e t o c o n f o r m t o t h e s e s t a n d a r d s . I n g r o u p w o r k , t h e p e e r g r o u p h e h a v i o u r c a n b e g u i d e d t o c o n s t r u c t i v e p a t t e r n s . I n t h e f a m i l y , t h e members r e q u i r e s p e c i a l a d j u s t m e n t a n d r e a d j u s t m e n t t o one a n o t h e r t o p r e s e r v e e m o t i o n a l b a l a n c e i n t e r m s o f b e h a v i o u r , a t t i t u d e s , o b l i g a t i o n s a n d r e s t r i c t i o n s . A n y c h a n g e , s u c h a s b i r t h , d e a t h , e m o t i o n a l e s t r a n g e m e n t u p s e t s t h e f a m i l y e q u i l i b r i u m . L e s s c o n s p i c u o u s c h a n g e s i n c l u d e d e v e l o p m e n t a l s t a g e s t h r o u g h w h i c h c h i l d r e n p a s s , w h i c h r e q u i r e t h a t t h e p a r e n t s m o d i f y t h e i r r e l a t i o n s h i p a n d r e n o u n c e g r a t i f i c a t i o n s t h e y h a d p r e v i o u s l y r e c e i v e d f r o m t h e i r c h i l d r e n . I n p u b e r t y , t h e c h i l d w i t h d r a w s f r o m h i s r o l e a s r e c i p i e n t o f t h e p a r e n t s ' a f f e c t i o n and g u i d a n c e e x p r e s s e d i n f o n d l i n g , k i s s i n g , f e e d i n g , p r o t e c t i n g , p u n i s h i n g , w i t h e m p h a s i s a c c e d i n g t o t h e f a m i l y p a t t e r n . The p a r e n t s ' r e a c t i o n t o t h i s w i t h d r a w a l may be a c c e p t a n c e a n d a d j u s t m e n t t o t h e new d e v e l o p m e n t ; o r i t may be r e s i s t a n c e t o c h a n g e w i t h i n a b i l i t y t o a d j u s t t o new d e v e l o p m e n t ; o r t h e r e may be a c o n f l l c t u a l r e a c t i o n w i t h a m b i v a l e n c e a b o u t t h e c h a n g e . 18 The adolescent, as part of the maturation he i s under-going, w i l l change i n his emotional or f e e l i n g l i f e . His family ceases to.be the legitimate place to display his f e e l i n g . Sexual components i n his emotional l i f e make the family a prohibited retreat for the f u l l s a t i s f a c t i o n of his f e e l i n g l i f e . The maturing c h i l d , then, seeks to replace home relationships with outside contacts. He replaces parental influence with ideational and conceptual spheres and transforms family pat"r terns into group standards of conduct. There i s a p a r t i a l transference of affectionate r e l a t i o n s h i p with the family to persons outside the primary group. The family may f e e l this i s a step away from them and try to prevent t h i s . The adoles-cent i s sensitive to the reactions of his parents because he cannot n u l l i f y his childhood l o y a l t i e s to his mother and father. Usually, unstable family relationships are created by t h i s interplay and both the parents and the c h i l d have inconsistent attitudes to each other. Because the parents' adolescence i s often the only basis for understanding his *tean age c h i l d , there arises misunderstanding between generations. ; In our present age of delayed marriages, we f i n d the middle-aged parent and the adolescent c h i l d . Jealousies may spring up between the mother, undergoing menopause, and the daughter, beginning menstruation. An older s i b l i n g who presumably has more freedom and a more detached and mature rel a t i o n s h i p with his parents, may arouse tremendous jealousy i n his adolescent brother or s i s t e r . The l a t t e r may carry on the battle he meant for his parents with this s i b l i n g , since he can do so with less g u i l t . 19 The adolescent struggles with his future as well as his present. He'faces problems of choice i n vocation, mate, when to marry, sexual needs, acceptance of-masculine or feminine r o l e , and r e l i g i o u s and p o l i t i c a l a f f i l i a t i o n . These problems are a l l the more d i f f i c u l t today because there are no well defined s o c i a l customs, and parents are confused too. In searching for p o l i t i c a l convictions, the adolescent may make family p o l i t i c a l arguments the basis upon which he establishes his independence. The boy often feels he cannot be independent u n t i l he can prove his economic independence. I f he i s finan-c i a l l y dependent on his family, his emotional independence seems more d i f f i c u l t , as parents cannot e a s i l y grant complete inde-pendence of action to a c h i l d of any age, whom they s t i l l support and. who s t i l l shares their home. Vtfithin each individual there i s conflict between inherent impulses and the requirements of r e a l i t y . By adolescence, the conscience takes part i n t h i s c o n f l i c t . The adolescent struggles to f i n d a pattern of behaviour which w i l l give d i r e c t or sub-s t i t u t e g r a t i f i c a t i o n for i n t e r n a l l y determined Impulses within a framework of r e a l i t y and without v i o l a t i o n of the r e s t r i c t i o n s of his conscience. Before he reaches an actuate solution, manifestations of the c o n f l i c t appear i n his behaviour. In any period of c o n f l i c t , c h a r a c t e r i s t i c s of behaviour develop which are manifestations of an I n t e n s i f i c a t i o n of p a r t i a l l y unresolved aspects of e a r l i e r c o n f l i c t s . The individual may not only prove unable to deal with the new situation, but his uncertain adjustment to the old problems may also break down. Such di s i n t e g r a t i o n of adjustment may re s u l t in.the appearance of symptoms related to the immediate c o n f l i c t , but coloured by 20 other inadequately resolved c o n f l i c t s of the past as well. The defenses b u i l t up to minimize the pain of e a r l i e r c o n f l i c t s w i l l probably be used again to deal with the new d i f f i c u l t i e s . The adolescent presents a composite picture of a re c a p i t u l a t i o n of the paychological past within the framework of the present. Prom infancy, the parents provide protection to the c h i l d . The adolescent, faced with situations which he cannot master, and which frighten him, turns to his parents for support and comfort. As he becomes older, he i s able to master more and more of his environment, and turns less and less to his parents. The drive towards maturity and independence r e s u l t s i n the adolescent's expo^sing himself to unfamiliar situations that make new demands on his capacity to integrate his world. Where i n the past he permitted his parents or other adults to determine the situations to which he was exposed, now he refuses the guidance of his parents; or exposes himself to these new experiences without his parents' knowledge. In this way he i s challenged by situations he i s unable to meet, and he conse-quently becomes frightened. To handle t h i s f r i g h t , he turns to his parents or other adults for support. I f the s i t u a t i o n i s not too t e r r i f y i n g , his dependence on others i s no greater than the actual s i t u a t i o n demands. Because of deeper emotional significance, however, he may not gain the reassurance he needs from a mature dependent r e l a t i o n -ship. His r e s u l t i n g panic may bring about a regression and he w i l l return to the f a m i l i a r pattern of i n f a n t i l e dependence. When this happens and he gets the needed support, his strength w i l l increase. He then sees himself as returning to childhood through his regression and his pride is hurt. Therefore, he 21 feels he must protest against this f l i g h t into childhood and his anger at himself w i l l form an attack against those who are aware of his defeat. The adolescent i s ambivalent to those persons closest to him. Through anxiety, he shows i r r i t a t i o n and resentment to his parents. Inherent i n adolescence, Is the discovery of new worlds to conquer and hew capacities i n himself that are to conquer these. Resentment;,of r e s t r i c t i o n s of this opportunity r e s u l t s i n h o s t i l i t y towards his parents. At the same time thi s h o s t i l i t y frightens him because of his fear that i t w i l l r e s u l t i n the destruction of the parents' love for him. I f he accepts t h e i r r e s t r i c t i o n s to hold this love, he w i l l face f r u s t r a t i o n r e s u l t i n g from lack of g r a t i f i c a t i o n of his own desires. Resolutions of these c o n f l i c t s w i l l come when the adolescent r e a l i z e s that h o s t i l i t y k i l l s neither his parents or their love; so that i t i s safe to hate love objects; when he finds substitute outlets that are permissable; and when he develops s k i l l s that make i t possible for him to engage i n previous forbidden behaviour. Casework and the Adolescent In the caseworker, the adolescent i s seeking an adult who has solved some of the problems he i s f a c i n g — n o t another adolescent. He wants to know that there are answers, but at the same time he wants to be free to choose the one that meets his needs most. Due to the intensity of the emotional t i e involved i n i d e n t i f i c a t i o n with the person helping him, the adolescent i s not capable of making wise choices as he imitates 22 adult behaviour. This throws muchrresponsibility onto the adult chosen as his ego i d e a l . The adult who works best with adolescents, i s the one who i s comfortable i n his own adjust-ment, but who i s genuinely tolerant of other constructive patterns of adjustment. The caseworker must work towards strengthening the forces i n her adolescent c l i e n t which lead to adult solutions of his c o n f l i c t s and to help the adolescent u t i l i z e the adolescent period optimally. The adolescent needs the oppor-tunity to be independent, but he also needs guidance i n undertaking new experiences. He therefore w i l l benefit from a framework that w i l l l i m i t the sphere of his a c t i v i t y to challenging, but achievable, goals. The adolescent i s helped, not only by the opportunity to try out his newly found strength i n new areas of independence, buttby assurance of support when he becomes baf f l e d , i n e f f e c t i v e , or frightened. He therefore needs a person who w i l l l e t him be dependent when he i s frightened, but who wiD. not demand continued dependency when he f e e l s more assured and adequate i n an independent r o l e . The most obvious aspect of the ^dolescent "crush",on the person meeting his dependency needs, i s i t s sexual impli-cation. The sexual drive of the adult i s directed towards on p a r t i c u l a r person; but usually this sexual component of the adolescent rel a t i o n s h i p is d i f f u s e d . Of primary s i g n i f i -cance i s the dependeny needs he i s seeking to g r a t i f y . Because of awakening sexual feelings, which are not goal directed, the desire for dependency g r a t i f i c a t i o n becomes e r o t i c i z e d . That i s , dependency <and' sexual needs of the 23 adolescent are fused i n the worker-client r e l a t i o n s h i p . This sexual interest lessens i n intensity as his dependency needs are adequately met. The adolescent does not become involved i n t h i s "crush" unless he has strong needs for some g r a t i -f i c a t i o n that he believes this other person can meet. It would seem to the writer that this i s of utmost significance i n discussing adolescent resistance to casework as d i f f e r i n g from t:hat of thej adult's. The method i n which t h i s sexual component i s handled by the professional caseworker can do much to overcome seeming resistance to the help proffered. The h o s t i l i t y present i n the worker-client r e l a t i o n s h i p may be a d i r e c t outcome of the adolescent's need to deny the existence of i n t e n s i t y of f e e l i n g for the older person due to the frightening quality of this r elationship to him. This Is again related to the family s i t u a t i o n , i n which, at adolescence, the sexual component i n a l l his enotional l i f e makes the family a dangerous source of s a f i s f a c t b n for his emotional needsm leading to his seeking his emotional s a t i s -factions outside the family. The caseworker must.realize that the danger implied to the adolescent i n his intense feelings towards her can be overcome and d i l u t e d through meeting his dependency needs. Otherwise, a new h o s t i l i t y w i l l emerge on the part of the adolescent through his anger at the worker for f a i l i n g to meet his dependency needs. Sometimes the adolescent's dependency needs w i l l be too great to be met i n a professional r e l a t i o n s h i p , and this must be recognized with him. This h o s t i l i t y apparent i n the treatment r e l a t i o n s h i p i s always of an a r t i f i c i a l nature and serves several r o l e s . 24 The adolescent may be seductive to a t t r a c t the attention of the other person. He may behave .to. provoke punishment, which permits eroticism of su f f e r i n g the punishment w i l l bring. The h o s t i l i t y may be an exaggeration of normal ambivalence, the adole scent f e e l i n g that the demands imposed are beyond his capacity. It may also be the means of denying r e j e c t i o n and the implications of his own inadequacy. In the professional r e l a t i o n s h i p , the adolescent i s seeking, primarily, someone by whom he f e e l s completely accepted. In addition, he seeks protection from frightening r e a l i t y and help i n dealing with his own internal drives. He wants a guardian who w i l l protect him much as his parents did, and someone to i d e n t i f y with, since he i s not sure, what kind of person he wants to be. . . . t In this sort of r e l a t i o n s h i p , the adult must maintain a role that offers g r a t i f i c a t i o n to the ado&escent's dependency needs. This strengthens the young person's ego capacity to deal with his int e r n a l c o n f l i c t s and his external r e a l i t y . The adult must have a b i l i t y to recognize evidences of growing Independence i n the adolescent and to foster i t . The adolescent should not f e e l he w i l l lose the g r a t i f i c a t i o n he has found i n th i s r e l a t i o n s h i p i f he establishes himself as a more independent person. The caseworker, therefore, has a dual function: t o accept the adolescent's dependency and to encourage his matur-ation. A " l i g h t " touch i s indispensable i n the worker's re l a t i o n s h i p to the adolescent. It is often reassuring t o the adolescent i f the caseworker can reveal a sense of humour about 25 the adolescent's problems and show the adolescent the humourous aspects of the s i t u a t i o n . Much of the reassurance of this method i s the adolescent's knowledge that the adult i s not overwhelmed by the problem. The adolescent's behaviour can be understood only i n the l i g h t of a defense against anxiety. The i d e n t i f i c a t i o n process i s important to successful adulthood. "A caseworker who worked c h i e f l y with delinquent adolescents used to say that the c h i l d who lacks the parent of his own sex i s the most unfortunate and the most l i k e l y to become delinquent." 1 Normal i d e n t i f i c a t i o n with the parent makes formation of new attachments easy. The caseworker must become a new vehicle of i d e n t i f i c a t i o n since the new r e l a t i o n -ship to an adult Is necessary to undo the harm or make up the lacks of the old. Some professional persons say i t i s there-fore i m p l i c i t that the caseworker who deals with the adolescent be of the same sex as the c l i e n t . Since many of the adolescents the caseworker sees are those who have not formed a s a t i s f a c t o r y i d e n t i f i c a t i o n with the parent of the same sex, there may be much resistance to i d e n t i f i c a t i o n with the worker. It would seem, therefore, that the choice of worker should be related to the needs of the p a r t i c u l a r adolescent, with awareness on the part of the worker, of the dynamic ramifications of his feminine or masculine role on his young c l i e n t . Any d i r e c t revelation of unconscious c o n f l i c t by the adolescent is : evidence of a temporary weakening of the ego structure through a lack of defenses. It i s therefore important — — — — — 1 Ross, Helen, "The Caseworker and the Adolescent", The  Family, November, 1941, p. 235. 26 to concentrate on reality Issues and the building of the adolescent's defenses. The adolescent can be protected,, from external situations which excessively stimulate his internal drives. He can be helped to redirect his l i b i d i n a l drive towards less anxiety stimulating love objects. He must be given opportunity to sublimate his unacceptable primitive drives into socially acceptable psychologically constructive paths. There is value in sane restrictions of the adolescent, but these limits should not prevent the adolescent from carrying through successfully a part of his revolt. At the same time he should not be freed from a l l gui l t . He needs understanding of the nature of his guilt in order to use i t constructively. The adolescent needs his parents. There is a danger i f the caseworker identifies with the adolescent and rejects his parents. This may result in pressing the adolescent to escape from his parents prematurely. H e may fear taking this step as his security rests with his parents. Frightened by the stimulus of the other person, the adolescent, in acute anxiety, reverts to greater dependency on his parents in order to negate the dangerous temptation. Or unable to revolt, he may project his own inadequacy and guilt onto the adult who encourages the revolt. His projection of inadequacy and guilt onto the worker w i l l rob him of the drive to maturity. The manifest situation, under obvious small episodes encouraging emancipation, may only be the tip of the iceberg. Encourage-ment to emancipate in minor details, may mean to the adolescent, 27 encouragement to abandon a l l parent representatives. Such abandonment is not safe except afc new standards replace the old ones. The development of new standards takes place through the adolescent's relationship with a parent-surrogate, who offers less paralyzing restrictions. The development also takes place through the adolescent's internal growth. Unless the adolescent has accepted a mature standard, broad revolt against his parents may prove disastrous to the future pattern of his behaviour. The adolescent does need support in freeing himself from his parents, but he should be encouraged to gain his freedom by evolution, not revolution. The Present Study Theoretically, some basis for considering adolescent resistance as a concomitant of the emancipatory strivings of this stage of development has been formed. The sexual com-ponent pervading his entire emotional l i f e , makes an intensive relationship with an adult person threatening to the adolescent who is attempting to achieve his emotional satisfactions with persons outside the family. The characteristic secretiveness of the adolescent does not encourage discussion of his deepest problems in a casework relationship. The adolescent rebellion against old standards and controls is apt to carry over to the casework treatment situation, i f the stimulus bringing him to the agency is externalized in his parents, the school or other authoritarian figures. Through study of actual cases involving adolescent resistance to casework, It wi l l be attempted to ascertain 28 whether patterns evolve that bear out this theory. This study w i l l take place within the Child Guidance C l i n i c of Vancouver. Since most cases coming to the attention of th i s agency Reflect some degree of breakdown in the parent-child r e l a t i o n s h i p , the rela t i o n s h i p of this breakdown to emancipatory e f f o r t s of the adolescent or to pathological f a m i l i a l relationships will be an important distinguishing f a c t o r . Three age groups, of both sexes,will be studied: the pre-adolescent from 11 to 13 years; the adolescent from 14 to 16 years; and the post-adolescent from 17 to 19 years. Only those cases discussed at a diagnostic conference, including p s y c h i a t r i s t , psychologist, public health nurse and s o c i a l worker; and which have begun treatment, w i l l b§ presented. Im this way, i t Is hoped that s u f f i c i e n t background information on each adolescent w i l l be obtained to ascertain h i s pos i t i o n i n the family as oldest, youngest, or middle s i b l i n g ; the marital s i t u a t i o n of the parents; and some picture of the i n t e r -family r e l a t i o n s h i p s . In addition to the main l i n e of inquiry--the adolescent's resistance to casework as related to emancipatory e f f o r t s and psychosexual development—the relationship of his resistance to the problem presented and the source of r e f e r r a l cannot be overlooked. How the adolescent's resistance to treatment is effected by the resistance or lack of resistance of his parents to treatment i s extremely important, but this area w i l l not be studied here, due to the enormity of the entire question. The writer feels that t h i s l a t t e r inquiry deserves a study of i t s own. The source of r e f e r r a l may also be a r e a l i s t i c factor i n the adolescent's resistance as i t may be an 29 a u t h o r i t a r i a n " p e r s c r i p t i o n " from the p u b l i c or i n d u s t r i a l s c h o o l , or the f a m i l y doctor; or i t may be the p a r e n t s ' i n s i s t e n c e , only, that b r i n g s the adolescent to the caseworker. I t w i l l be attempted to formulate from the case m a t e r i a l , the major stimulus which led. the a d o l e s c e n t to the c h i l d Guidance C l i n i c . A proposed o u t l i n e of i n q u i r y , as d e l i n e a t e d i n Appendix A,, w i l l be used In g a t h e r i n g i n f o r m a t i o n . In t h i s study, An attempt w i l l be made to d i s c e r n p a t t e r n s of behaviour, m a n i f e s t i n g r e s i s t a n c e , that are p e c u l i a r to the adolescent age group, and to c l a s s i f y these on the b a s i s of these p a t t e r n s . I t w i l l be attempted to diagnose the r e s i s t a n c e a c c o r d i n g to dynamic m o t i v a t i o n , and to see i f t h i s d i a g n o s i s bears any p o s i t i v e r e l a t i o n to the adolescent p e r i o d of development. This study d e a l s only w i t h the r e s i s t a n c e of the adolescent to casework help, and does not go i n t o the b e n e f i c i a l r e s u l t s of h i s c o n t a c t w i t h the C h i l d Guidance C l i n i c . Furthermore, i t does not d e a l , i n any separate way, w i t h the casework methods used w i t h these a d o l e s c e n t s . The primary q u e s t i o n i s whether or not the r e s i s t a n c e of the adolescent to casework help i s r e l a t e d to the emancipatory e f f o r t s o f t h i s p e r i o d and the psychosexual c o n f l i c t s o f the age. II MANIFESTATION OF RESISTANCE BY THIRTY ADOLESCENTS IN CHILD GUIDANCE CLINIC TREATMENT The thirty youngsters who form the core of this study are adolescents whose resistance to casework played a pertinent role in the outcome of their treatment. The caseworkers at the Vancouver Child Guidance Cl in ic provided the writer with the names of adolescents from their current or past case loads, whose resistance was noted in the casework process. Explanation of Schedules Two schedules^were teed to aseess the resistance shown "by the individual adolescents in treatment. The f i r s t dealt with the keeping of appointments and interviews and paid particular attention to missed and cancelled appointments and late arrivals for interviews. The second schedule was related to the degree of participation in interviews. I n i t i a l , exploratory and subsequent interviews were separated in this assessment. I n i t i a l interviews were the f i r s t two or three intake interviews held with the cl ient prior to his acceptance by the c l i n i c team for diagnostic study. Exploratory interviews were those interviews held previous to the diagnostic assessment by the c l i n i c team, of the c l ient 's d i f f i cu l ty , but held after the c l ient 's acceptance for diagnostic study. The subsequent interviews were those held following the diagnostic conference, in which treatment was in i t ia ted . Found in Appendix A . , second page. 51 High degree of p a r t i c i p a t i o n i s defined by the writer, as spontaneous discussion of problems accompanied by some degree of insight into the reasons for d i f f i c u l t y and some acceptance by the c l i e n t of the r e s p o n s i b i l i t y for change and the need for working on the d i f f i c u l t y . Moderate degree of p a r t i c i p a t i o n describes those c l i e n t s .  who spoke f a i r l y r e a d i l y about th e i r problem, but who assumed l i t t l e or no r e s p o n s i b i l i t y for the d i f f i c u l t y , or who had l i t t l e Insight into t h e i r problem. Ambivalence was assessed by the writer, on the basis of the c l i e n t ' s swings between wanting help and fear of becoming involved i n personal changes. These c l i e n t s d i f f e r e d from those showing a moderate degree of p a r t i c i p a t i o n i n that they at times had some degree of insight, but their concurrent fear of change and anxiety i n the face of the i r understanding served to push th i s insight into the background. At times i t was thi s very insight that provoked the resistance seen i n interviews. It may be noted that the c l i e n t who i s ambivalent, may be much easier to involve i n casework than the c l i e n t who shows moder-ate participationbut no insig h t . It must be stressed here, that ambivalence i s present i n a l l these adolescents who show resistance, but keep their appointments at the c l i n i c . There must be c o n f l i c t i n g feelings present or they would not come for t h e i r interviews. However, i n thi s p a r t i c u l a r group c l a s s i f i e d as ambivalent, this waivering between wanting help and yet r e s i s t i n g i t , was the most s t r i k i n g c h a r a c t e r i s t i c i n thei r behaviour. This group might also be c a l l e d one i n which equal degrees of p a r t i c i p a t i o n and resistance was present. In the other c l a s s i f i c a t i o n s , although ambivalence was ce r t a i n l y 32 present; i t was not the most accurate description of the adolescent's behaviour. The client showing a moderate degree of resistance to casework help is the person who, consciously or unconsciously, guards himself against sharing his d i f f i c u l t i e s with the caseworker. Whereas relationship is the core of casework regardless of the degree of resistance shown by a client, in this and the following classificationi the capacity or toler-ance the client has for relationship is of particular s i g n i f i -cance. The previous relationships of this client have considerable import in his readiness to share his personal dilemmas with a stranger, the caseworker. This is the client who may keep appointments, but once in the interview situation, produces l i t t l e but superficialities to work on. The client showing a high degree of resistance to treatment is the client who is overtly hostile to "interference" in his affairs. He is the person who consciously blocks any efforts to help him change. He is the person who denies any problem; who sees the c l i n i c contacts as a waste of time. Due to problems of relationship and family d i f f i c u l t i e s , he is too threatened to even see a problem. Perhaps this is the adoles-' cent who is so threatened by his problem, that his only means of functioning l i e s in his a b i l i t y to fantasy that things are going smoothly. The casework process, i t s e l f , threatens his defenses and thereby his functioning. What can he do but fight against the forces that perturb his present equilibrium?. Because case records are not compiled for the purpose of charting a client's resistance, solely, there is sometimes 33 a lack of evidence of the client's participation in interviews. In the majority of .cases, l i t t l e direct reference Is made to the resistance of the client or his participation in interviews. It has thus become necessary for the writer to make her own assessments of the degree of resistance shown by individual adolescents. In some cases, comments by the worker have been used when available. There was not enough data, in these fiSase records^to allow the client's personal assessment of his participation to be made a valid part of this assessment, how-aver valuable this might have been. Of course^the adolescent client w i l l not maintain the same degree of participation throughout treatment. For pur-poses of presentation, the cases have been classified according to the patterns of resistance. A brief presentation of some of the adolescents, their home situation and the course of their resistance is attempted in this chapter. Composition of Studied Group Of the thirty adolescents studied; eighteen were in the pre-adolescent group (11 to 13 years); eight in the adolescent group (14 to 16 years);and four, in the post-adolescent group (17 to 19 years). Only four of the thirty were boys; each of these being in the pre-adolescent group. The problems presented by this group are varied. Perhaps the greatest number presented problems of a d i s c i p l i n -ary nature. Parents complained of insubordination, stubbornness, and rebellion of these youngsters towards parental control. Another group showed delinquent behaviour, consisting of lying, stealing and promiscuous sexual behaviour. In this latter 34 group, the problems presented by the adolescent had IncurrSd pressure from the community and sometimes the courts as well as parents. A number of the adolescents showed physical symp-toms with no organic basis. In t h i s group are included those youngsters suffering from eneuresis as well as physical i l l n e s s . School d i f f i c u l t i e s were also prominant among the t h i r t y adolescents. Among these l a t t e r youngsters are included not only those adolescents who were backward i n school, but those who wished to terminate their education. D i f f i c u l t i e s i n r e l a t i o n s h i p with adults and peers was another complaint often heard from parents of these youngsters. Often the i n d i v i d u a l adolescent presented a number of these problems at onset.. Source of Referral Three adolescents made personal application to the c l i n i c for help. Of these three; two participated f u l l y i n i t i a l l y , one was ambivalent. But usually, adolescents do not apply f o r c l i n i c help themselves. "It i s even more true of adolescents than of adults that the damaged ego cannot take steps to a v a i l i t s e l f of needed help." Therefore these adolescents are brought for casework help--often against their wishes--by parents or other persons in authority. Of the 27 adolescents referred to the c l i n i c by adults, 10 were brought by parents; 3 by public health nurses', 3 by private physicians; 5 by the school and 4 by the Juvenile Court •^Ellsworth, Dorothy, "Precocious Adolescence In Wartime", Reprinted from Ehe Family, March, 1944. or p o l i c e . The i n i t i a l resistance of these youngsters, as related to the source of r e f e r r a l , can be seen In Figure 1, page 36. A s l i g h t c o r r e l a t i o n can be seen between the source of r e f e r r a l and the resultant i n i t i a l resistance. How-ever, by far the most important factor i n this i n i t i a l resistance is the stimulus under which the adolescent came to the Chi l d Guidance C l i n i c for help. These two things--the source of r e f e r r a l and stimulus--are quite d i f f e r e n t ; for although the source of r e f e r r a l i s the same i n two cases, i t can have a vastly d i f f e r e n t meaning for the two adolescents involved. For instance, one g i r l was referred by the police through the Family Welfare Bureaus But they did so on behalf of the g i r l , who had been locked out of her home by her mother. In t h i s case the stimulus was r e a l l y the g i r l ' s own desire to better her si t u a t i o n . On the other hand, another boy was referred by the Juvenile Court. He c e r t a i n l y regarded this as an authoritative r e f e r r a l , because neither he nor his parents were able to accept, any r e s p o n s i b i l i t y for his a n t i -s o c i a l behaviour. It was a l l the fau l t of the "bad boys" he associated with! Thus, the stimulus i n thi s case rested e n t i r e l y with the court, not with the boy or his family. The r e l a t i o n s h i p between i n i t i a l , resistance and the stimulus for seeking help can be seen i n Figure 2, page 37. It cannot be emphasized too often that casework does not function to please a t h i r d person, and that the desire for help must be present or stimulated In the c l i e n t before progress can be made. Of the t h i r t y adolescents: 3 sought help of their own i n i t i a t i v e ; 7 at the suggestion or advice of others; 3 at pressure from others; 3 at tie authoritarian 36 Figure It Source of Referral and I n i t i a l Resistance f Source of Referral Total Cases I n i t i a l Resistance Personal application 5 1 High Resistance 1 Moderate Resistance 3 High P a r t i c i p a t i o n Health. C l i n i c > 2 1 High Resistance 1 Moderate P a r t i c i p a t i o n School 5 1 High Resistance 2 Moderate Resistance 2 Moderate P a r t i c i p a t i o n Children's Agency 2 1 Moderate Resistance 1 Moderate P a r t i c i p a t i o n Court - 3 1 High Resistance 1 Moderate Resistance 1 Moderate P a r t i c i p a t i o n Physician 3 1 High Resistance 2 Moderate P a r t i c i p a t i o n jParents 9 j 1 High Resistance 1 2 Moderate Resistance 1 1 Ambivalent S 3 Moderate P a r t i c i p a t i o n 1 2 High P a r t i c i p a t i o n 37 Figure 2: Stimulus and I n i t i a l Resistance Stimulus Total Cases I n i t i a l Resistance Personal I n i t i a t i v e 3 1 Ambivalent 2 High P a r t i c i p a t i o n Suggestion or Advice of Others 7 1 High Resistance 2 Moderate Resistance 3 Moderate P a r t i c i p a t i o n 1 High P a r t i c i p a t i o n Pressure from Others .3 • 3 Moderate Resistance Authoritarian Direction of Others 12 3 High Resistance 3 Moderate Resistance 1 Ambivalent 4 Moderate P a r t i c i p a t i o n 1 High P a r t i c i p a t i o n Parental D i r e c t i o n I 5 1 High Resistance 1 Ambivalent 3 Moderate P a r t i c i p a t i o n 1 1 High P a r t i c i p a t i o n 38 orders of others; and 4 at their parents' insistance. There was increasingly more resistance shown as the stimulus was further removed from the adolescent, himself. Family Setting The family setting of these t h i r t y adolescents varied greatly i n every way but one. Every adolescent was involved in serious parent-child r e l a t i o n s h i p d i f f i c u l t i e s . A picture of the family settings.of these youngsters i s given in Figure 3, page 39. Of the t h i r t y children studied; only 12 came from homes were both parents were l i v i n g together. Of these 12 homes; 11 suffered from d e f i n i t e marital discord. In one of these 11 homes, the main d i f f i c u l t y between the parents was the d i s c i p l i n e of the children. One couple, only, seemed compatible, and i n this family, the wife played the role of mother to her husband as well as to the children. One couple had severe f i n a n c i a l d i f f i c u l t i e s and i t was the second marriage for the man. In another family there was much violence directed towards the three children. The patient, a g i r l of 17, was i n two foster homes during her contact with the c l i n i c . One woman regarded her marriage as happy i n i t i a l l y , while she recognized her husband's d i c t a t o r i a l manner as an4mpediment to a good relationship with the teen-age children. Later, this woman focussed on the marital s i t u a t i o n and was referred to the Family Welfare Bureau. Two adolescents came from homes i n which the parents were separated. In one family, the father had been out of the home for eleven years as a chronic patient i n a nursing home. Marital ,relationships had always been bad. The mother Figure 5: 39 Family Setting Legend Parents l i v i n g together Marital f r i c t i o n Parents Separated Parents divorced & remarried Mother widowed Child adopted Child i l l e g i t i m a t e Child a ward 3/10"- 1 adolescent 40 l e f t the father while she was pregnant with the patient and their was an older brother who was i l l e g i t i m a t e . The other couple were l e g a l l y separated, and the patient, Edith, 16, l i v e d with her father during the week and her mother on week ends. There were three older children i n this family, a l l married. Three families were divorced and remarried. Two of the adolescents l i v e d with the remarried parent, thus having a step-parent i n the home. Roxie, 12, l i v e d isith her father and step-mother and her s i s t e r , 9. She also had two step-brothers 2 and 1. L l l a , 13, l i v e d with her mother and step-father of eight months. She was the only c h i l d and the mother f e l t the g i r l was jeopardizing her new marriage. One.adolescent g i r l l i v e d with her mother, while her father was remarried. Sheila, was 15 and the youngest of three children. Her brother was 23, her s i s t e r 19. Sheila's mother used the g i r l ' s mis-behaviour as an excuse to contact her ex-husband. Five adolescent g i r l s l i v e d with t h e i r widowed mothers. Sandra, now 13, l o s t her father when she was 11 months o l d . Her father had been i l l f o r 5 years before his death, and she was an unwanted c h i l d . Betsy, now 12, l o s t her father on her birthday, several years ago. The attitude of Sandra and Betsy towards their fathers was not recorded. The other three fatherless g i r l s , Betty, 13; Joan, 17; and Noreen, 16; a l l ide a l i z e d t h e i r fathers. Betty was 13 when her father died. Her parents had separated nineteen months before her father's death and Betty f e l t her mother had deprived her of her i d o l i z e d father prematurely. She had two s i s t e r s , 17 and 12. 41 Joan was 4 when her father died. Her mother l e f t her with her paternal grandparents and aunt at this time and did not reclaim Joan until she was 16. At this time, the mother became aware of the paternal relative's attempts to alienate the g i r l from her mother. Even then Joan did not live with her mother, but In a boarding house. Nc-reen lost her father when she was 12. Pour of the thirty adolescents were adopted. Two of the couples were living together at the time of referral to the Child Guidance Cl i n i c . Florence, 16, was fortunate in that her adoptive parents got along in a comfortablefashion. There was some f r i c t i o n in the home, however, due to the presence of the maternal grandmother. Florence was the youngest of 5 children in her natural family and was given up for adoption during the depression of the 1930's. She naturally resented this relinquishment by her natural parents. She professed a desire to meet her real siblings. She had one adopted brother, age 12. Penny's adoptive parents disagreed about the freedom that should be allowed a g i r l of her 13 years. She was adopted at 15 months of age.and the adoptive parents con-tributed Penny's d i f f i c u l t i e s solely to heredity. Ann's adoptive father was widowed and remarried. She was adopted as an infant following the death of the adoptive parents' natural child. When she was seven, her adoptive mother died giving birth to a son, now age 5. At c l i n i c contact, Mr. Quist regarded his second marriage as considerably strained by 12 year old Ann's presence. 42 Dorothy's adoptive parents are divorced. She r e a l l y never knew her adoptive father, who I n i t i a t e d the adoption, as he joined the army Immediately following the adoption and then went "astray". The adoptive mother's relationship with Dorothy i s immeasurably affected by the father's desertion and her suspicion that Dorothy i s actually the natural c h i l d of her husband. Three children were i l l e g i t i m a t e and kept by the natural mother. John's mother married his father following one marriage when John was one. year old and subsequent divorce. The second marriage was unhappy, also. The husband abused. John's mother ph y s i c a l l y , indulged i n alcohol and refused to support his family. There was never any r e a l a f f e c t i o n between the parents. .Mrs. Owen regarded her husband merely as a meal t i c k e t for herself, John, now 13, and the f i v e younger children. George's mother married when George was 2, to give the boy a home. George did not know of his i l l e g i t i m a t e b i r t h . The step father was i n a nursing home with an incurable i l l n e s s at the time of c l i n i c contact. The marital r e l a t i o n -ship had always been unsatisfactory. George had one s i s t e r , age 10. He was 13. Wilma's mother died when she was l | r . She stayed with her grandmother immediately following her mother's death. She had been l i v i n g with an aunt for the past f i v e years. The aunt was l e g a l l y separated from her husband and was most r e j e c t i n g of her 13 year old niece. Wilma was i n four foster homes during her CGC contact, none of which appeared s a t i s -fying to either party. . 4 3 Grace was a ward of the Children's Aid Society. Her mother died when Grace was 9, her s i s t e r 6. She and her s i s t e r had been In several CAS foster homes. The r i v a l r y between herself and younger s i s t e r caused Grace's r e j e c t i o n from her t h i r d foster home. None of these children came from a complete or healthy family u n i t . The d i f f i c u l t i e s of adolescence have been accentuated by pathological family r e l a t i o n s h i p s . Disposition of Cases A l l these youngsters are disturbed in one way or another. A l l need help i n solving the problems involved i n growing up. But only four of the original t h i r t y youngsters are continuing treatment at the Child Guidance C l i n i c . (See Figure 4, page 44 for d i s p o s i t i o n of the cases referred t o ) . Of the 26 cases closed, one was referred to the Family Welfare Bureau because' the mother was more concerned with her marital d i f f i c u l t i e s and because the patient was unable to p a r t i c i p a t e i n c l i n i c treatment. Two cases were closed to the Children's Aid Society. This means a possible three more children who are receiving some sort of needed casework help. The other 23 cases were closed due to the resistance of the teen-ager; not because of sustained improvement or any other therapeutic consideration. Of the four open cases: three areproceeding in the company of the adolescent's continuing resistance. These three adolescents are continuing treatment under authoritative pressure from the Juvenile Court. The fourth adolescent, Dorothy, age 14, i s continuing treatment with a high gegree 44 Figure 4: Disposition of Cases Scale: I " - 10$ 45 of p a r t i c i p a t i o n — o n one condition--that she see the worker as a person apart from the c l i n i c . She regards the worker as her own idea, the c l i n i c as her mother's idea, and w i l l have none of the l a t t e r . Most of the 23 closed cases were terminated as a d i r e c t reailt of the adolescent's resistance. In one case, the worker terminated against the adolescent c l i e n t ' s wishes because the g i r l was showing such ambivalence and resistance i n the casework Interviews that there was only antagonism and acting out i n a destructive way during treatment. Of the t o t a l S6 cases closed by the c l i n i c , 16 adoles-cent c l i e n t s showed a high degree of resistance at the time of termination; 7 showed moderate resistance; 2 showed ambivalence and one showed moderate p a r t i c i p a t i o n . In the l a t t e r case, Diane, 16, showed moderate resistance i n the i n i t i a l and exploratory interviews. Only when her mother terminated contact did Diane show a positive attitude to the treatment s i t u a t i o n . When her mother was p a r t i c i p a t i n g highly i n the c l i n i c program, Diane would have none of i t , and missed and cancelled her appointments. Patterns of Resistance Each adolescent showed a high degree of i n d i v i d u a l i t y in the course their resistance took. These in d i v i d u a l patterns may be seen in Appendix B. I n i t i a l resistance did not seem to have much relationship to the subsequent p a r t i c i p a t i o n i n treatment. There was no co r r e l a t i o n betwSen the age of the adolescent and his i n i t i a l resistance. 46 Taking the 30 adolescents as a group, their i n i t i a l p a r t i c i p a t i o n can be seen i n Figure 5, page 47. The greatest group showed moderate p a r t i c i p a t i o n at intake. The second largest group, moderate resistance. High resistance was more common that high p a r t i c i p a t i o n . Ambivalence was the most uncommon behaviour of a l l . Thus the adolescents studied began their contact with some reservations at l e a s t . But they were not t o t a l l y undecided or ambivalent about treatment. Most of the youngsters had decided to p a r t i c i p a t e or r e s i s t with some degree of c e r t a i n t y . Throughout their contact with the agency, the adolescents studied showed four main patterns of p a r t i c i p a t i o n (see Figure 6, page 48). The majority, 50% of the group, manifested, a progressive degree of resistance during t h e i r treatment. The next largest group, 20%, showed swings i n resistance. The majority of t h i s 20% showed an increasing degree of p a r t i c i p a t i o n during the exploratory interviews, with more resistance i n i t i a l l y and terminally. The t h i r d group, 16 2/3% showed consistent p a r t i c i p a t i o n during their entire contact with the agency. This may have been t o t a l l y r e s i s t a n t or moderately participant; but i n any event their i n i t i a l degree of p a r t i c i p a t i o n continued unchanged through the exploratory and subsequent Interviews. This group of youngsters, p a r t i c u l a r l y , seemed to make no movement i n th e i r treatment. A l l three of these groups are interesting i n a casework study since an increased attempt must be made to help them work through their resistances to treatment i n the i n i t i a l interviews. 47 48 Figure 6: Manifestation of Resistance 49 Those adolescents who showed a decreasing degree of resistance throughout their c l i n i c contact were the smallest group of a l l , comprising only 13 l/3cfo of the t o t a l youngsters. As might he expected, i t was from the group showing th i s pattern of p a r t i c i p a t i o n that three of the four adolescents continuing treatment came. The other younster contlmiing treatment came from the group showing swings i n resistance. Two of the three youngsters referred to another agency came from the group showing progressive resistance during treatment. The other person referr e d came from the group showing swings i n p a r t i c i -pation. The second group, showing swings in p a r t i c i p a t i o n , brings many questions to mind which cannot be answered i n a general way. One wonders i f the swing into more p a r t i c i p a t i o n Is a result of the rel a t i o n s h i p between c l i e n t and caseworker. Again, even though the casework may be of the highest quality; this doesn't imply that the same degree of s k i l l i n handling resistance i s present. Again, the swing back into increased resistance raises the inquiry of why so? This could be many things: the material discussed i n Interviews; the treatment relationship i t s e l f ; outside influences i n the adolescent's l i f e s i t u a t i o n ; ad infinitum. It behooves us to look more cl o s e l y at thi s and to do so requires that the ind i v i d u a l adolescents be studied. This w i l l be attempted under the c l a s s i f i c a t i o n s set herein. That i s , the groups showing the c i t e d patterns of behaviour w i l l £e presented. 5 0 The course of resistance i n the ind i v i d u a l adolescents can be seen i n Appendix B. Although groups of adolescents did show a similar pattern i n the course th e i r resistance took; none were exactly the same i n the degree of resistance manifested. The in d i v i d u a l pattern of resistance shown by each teen-age was related to the i r l i f e s i t u a t i o n and the problems they presented. For this reason, the writer w i l l present some of the youngsters as they appeared at he Vancouver Ch i l d Guidance C l i n i c . Progressive Resistance Frances, 18, came to the c l i n i c on her own i n i t i a t i v e , complaining that she was unable to stand, on her own feet and that her parents d i d not understand her. She f e l t the l a t t e r was the cause of a l l her d i f f i c u l t i e s . She also complained that she had d i f f i c u l t y i n getting along with people. She showgd a high degree of p a r t i c i p a t i o n , i n i t i a l l y , as might be expected when she, herself, was seeking help with a problem which was d i s t r e s s i n g to her. Later, however, she became ambivalent, then highly resistant and withdrew from casework. As she entered further into the casework r e l a t i o n -ship, she was unable to take any r e s p o n s i b i l i t y for a l t e r i n g her s i t u a t i o n , was occasionally l a t e for appointments and showed a progressive lack of communication with the worker. We can deduce from Prances' example, that even when an adol-escent seeks help himself, i t does not mean he f u l l y compre-hends what his i n i t i a l application for assistance w i l l involve. 51 Si m i l a r l y , Thelma age 17, came to the c l i n i c with a personal desire, for help. Although she had been referred o r i g i n a l l y by the police to the Family Welfare Bureau, she saw this r e f e r r a l as a f r i e n d l y one rather than an authoritative one. She had been locked out of the house by her mother when the l a t t e r became disgusted with the g i r l ' s constant bickering with her family. The police were immediately concerned with th i s young g i r l ' s e v i c t i o n from home; but also by the fact that Thelma had made several s u i c i d a l attempts on her own l i f e . When Thelma was re-directed by the Family Welfare Bureau to the Child Guidance C l i n i c , she showed a high degree of p a r t i c i p a t i o n . This d i d not continue, however, and Thelma became progressively r e s i s t a n t In subsequent interviews. Towards the end of her contact, Thelma missed four appoint-ments i n a row. By the time the agency f i n a l l y located Thelma, they found she had l e f t the area with her family. Thelma's father was working out of town when she f i r s t came to the agency. The g i r l appeared most u n r e a l i s t i c about her father, talking about the good times they would have when they were back together again. Thelma had a broken nose suffered when her father h i t her a few years ago. His l e t t e r s to Thelma, while she was attending the c l i n i c , were malicious and punitive. He accused her of being f u l l of s e l f p i t y , having nothing wrong with her, and purposely upsetting the family through her actions. Following an extremely nasty l e t t e r from her father, Thelma stopped coming i n . She verbalized her intention of not getting better, so she could prove her father wrong i n his accusations. Neither Frances nor Thelma received much support from 52 their families i n t h e i r bid for help with their problems. Although the family situations were widely divergent, and the opposition to c l i n i c contact was much greater i n the case of Thelma's family, the r e s u l t was the same. Both g i r l s l e f t the treatment s i t u a t i o n before they had given themselves a chance to r e a l l y work on.their d i f f i c u l t i e s . These two g i r l s were the only ones with any r e a l desire for help i n i t i a l l y . June, 15, "dammed up" following her i n i t i a l interview i n which she participated quite f u l l y , although s u p e r f i c i a l l y . June's mother brought the g i r l to the c l i n i c because she had been s h o p - l i f t i n g and suffered from eneuresis. Although June sat i n the caseworker's o f f i c e with as much animation as a wooden puppetj when questioned, she i n s i s t e d that she would not come in i f she didn't get anything out of her c l i n i c contact, and continued to keep appointments. The worker f i n a l l y terminated when this wooden response continued despite her e f f o r t s to "contact" the g i r l . It i s obscure to the worker and the writer just what June did get out of her c l i n i c contact. I f one might conjecture, i t would seem that June was successful in pacifying her mother by her attendance at the c l i n i c , while she was also proving that "you can leada horse to water but you can't make him drink", i n her w oden response to casework. Shirley, 11, was described by her parents as d i f f i c u l t to d i s c i p l i n e , defiant and unappreciative. She showed moderate p a r t i c i p a t i o n at f i r s t contact, and. then progressive resistance. She stopped coming a l l together when she found out that her parents were also coming i n to see the same worker. It 5 3 c e r t a i n l y indicates a lack of mutual tolerance between parents and c h i l d when the former do not even discuss the fact of the i r p a r t i c i p a t i o n with their daughter. Even when the parents were transferred to another worker, Shirley refused to continue her contact. She showed considerable g u i l t about her negative comments concerning her parents I n i t i a l l y , and this was a further factor in her resistance. Roxie also showed moderate p a r t i c i p a t i o n i n i t a l l y . This continued u n t i l termination when she showed moderate resistance. Her step mother had been concerned because Roxie had been running away, stealing and l y i n g . She was f e a r f u l that Roxie would get into sexual d i f f i c u l t i e s as had her natural mother before her. She also viewed Roxie's behaviour as a threat to her marriage. Roxie's father tended to minimize the d i f f i c u l t i e s , and attributed most of the g i r l ' s problems to his wife's attitude towards the g i r l . Roxie was h o s t i l e towards her step mother and very attached to her father. Ifc was not unexpected then, that she took the same view as her father and tended to project a l l the blame onto her step mother. The parents' i n a b i l i t y to p a r t i c i p a t e i n the c l i n i c program also had a great deal to do with Roxie's ithdrawal. Sheila, 16, was referred by her mother because of her insolence, disobedience and r e f u s a l to work around the house. She showed ambivalence at f i r s t contact, and. then became moderately and highly r e s i s t a n t . Her mother used an authori-tative approach to the g i r l . The c l i n i c became just one more struggle. Sheila would refuse to keep her appointments; her 54 mother would use physical force to make the g i r l attend c l i n i c . The writer doubts that this c h i l d was everallowed to decide whether <br not she should p a r t i c i p a t e i n the c l i n i c program. There was no choice; she just cameJ Even though several of these adolescents, showing progressive resistance, were referred t> the Child Guidance C l i n i c under the most unfavourable conditions, none of them showed any r e a l problem i n p a r t i c i p a t i o n at intake. The writer would venture to say that there was resistance present i n i t i a l l y , however. That i t was not recognized sfc this point of intake meant that" the resistance under the adolescent's s u p e r f i c i a l acceptance of treatment was not worked through. Not u n t i l the resistance had reached a point where i t Interfered with the adolescent's continuation with treatment was i t r e a l l y recognized as a problem. I f nothing else, this does point out the fact that i n i t i a l p a r t i c i p a t i o n i s no guage of measurement to determine the adolescent's use of c l i n i c contact. Swings i n Resistance Those youngsters who showed a sudden reversal i n t h e i r degree of p a r t i c i p a t i o n are perhaps more in t r i g u i n g than any other group. Jo-Ann was ref e r r e d due to problems of s t e a l i n g . She i s only 12, yet her parents have expected her to pay her" own way by after school jobs. Jo-Ann came to the c l i n i c under pressure from the school board. She began interviews with moderate resistance, then p a r t i c i p a t e d moderately, only to swing back to a pattern of moderate resistance. She ran away from home several times during her c l i n i c treatment, was 55 charged with truancy at the Juvenile Court and was lat e r confined to the Detention Home for stealing. Interviews are continhing with Jo-Ann i n conjunction with the Juvenile Court. Jo-Ann's father i s punitive and r e j e c t i n g . He does not t r u s t his daughter, and even before there was any l e g a l grounds for committal to the Detention Home,.he saw this as a way of r e l i e v i n g himself of her r e s p o n s i b i l i t y . The c h i l d was acting out her father's d i s t o r t e d Ideas of women and whoredom and responding to her mother's unconscious condon-ation of her s t e a l i n g . There were enough disturbing events i n Jo-Ann's environment to preclude Jo-Ann's use of treatment. The environmental situations which arose during her contact would be s u f f i c i e n t to provoke reversals of attitude^ towards c l i n i c help. Wilma, now 13, was referred by the Children's Aid Society. She was an i l l e g i t i m a t e c h i l d whose mother died when she was 1§, thrusting her upon an unwilling grandmother. Later Wilma l i v e d with her aunt. Wilma was shunted back and fo r t h among r e l a t i v e s and regarded as the representative of a l l the family skeletons. She could see through her aunt's "pretended kindness". Wilma showed moderate p a r t i c i p a t i o n when she began interviews. This developed into high p a r t i c i -pation and then regressed into resistance and denial of any d i f f i c u l t y . I t was no wonder that Wilma was unable to continue to depend on the worker when she had never been able to depend on anyone before. She voiced her conviction that the only way to get along was to take the t o t a l r e s p o n s i b i l i t y for her own actions and plans. 56 Several occurrences i n Wilma's present s i t u a t i o n probably contributed to this reversal into an unwillingness to depend on anyone. During her contact with CGD, Will's aunt placed herein a convent which she described as "just l i k e a j a i l and what wilma needs". The aunt had originally-applied to Children's Aid for help with Wilma who was "defiant, destructive-, l y i n g and st e a l i n g " . Following a t r i p back east to canvas unwilling r e l a t i v e s to take the g i r l , the aunt Brought Wilma back to the c i t y and f i n a l l y consented to f o s t e r home placement. Unfortunately, Wilma was placed away from CG-C and was unable to continue treatment. Later, she was replaced i n the Qhildren's Aid Receiving Home and continued treatment. During this placement, Wilma' kept 30 appointments and missed another 15. She developed a dependent and po s i t i v e r e l a t i o n -ship with the worker during t h i s time, but became extremely threatened by this and began avoiding c l i n i c contacts. When the c l i n i c suggested increasing contacts to promote this close r e l a t i o n s h i p , Wilma showed a lack of willingness to take part i n this plan. It was f i n a l l y recommended that Wilma be placed i n a more Impersonal treatment centre and plans were i n i t i a t e d towards this end. Jo-Ann and Wilma, both, i l l u s t r a t e the e f f e c t pressing r e a l i t y has on the use the adolescents can make of treatment help. The writer does not maintain that only events m tiie l i v e s of these youngsters were responsible for the reversal of attitudes encountered i n treatment. However, i t does point up the need for the worker to be constantly aware of 57 what Is going on i n the adolescent's l i f e and to r e a l i z e that one hour a week in casework treatment i s hardly enough to o f f s e t the disturbances the teen-ager encounters in his every-day l i f e . At present there i s l i t t l e the worker can do to mitigate these environmental influences that work counter to treatment goals, other than to take agprotective a role as possible under the circumstances with the adolescent. What a difference we might have seen i n these two youngsters had there been a therapeutically oriented i n s t i t u t i o n i n which these two g i r l s could have resided during c l i n i c treatment • Consistent Resistance There i s no problem of recognition of resistance in this group of adolescents who began c l i n i c contact with a high degree of resistance and remained that way. The question which arises here i s why no movement could be made to reduce the resistance shown. Mary, 13, showed high resistance i n i t i a l l y , and continuously throughout her contact with the agency. She was referre d because of temper tantrums, doing poorly in school and because she aggravated her father.• Mary denied having any such d i f f i c u l t i e s . She was referred to Crease C l i n i c by a private p s y c h i a t r i s t while she was being seen at CGC. The case was then closed by CGC. Following 11 months i n Crease C l i n i c , Mary was again referred to CGC, by Crease C l i n i c . The o r i g i n a l p s y c h i a t r i s t then stepped i n and referred Marfr to another private p s y c h i a t r i s t . When the private p s y c h i a t r i s t to whom the r e f e r r a l was made, f e l t he could do nothing for 58 Mary and referred her back to CGC, the c l i n i c refused the r e f e r r a l on the basis that t h i s should go back to the o r i g i n a l p s y c h i a t r i s t . The agency's policy played some part in the f i n a l d i s p o s i t i o n of the case, but i t was not the entire story* Mary ran her parents very e f f i c i e n t l y and wouldnn'tallow her mother and father to go out together. She refused everything that came from her parents; refused to see them for the f r st two months she was confined at Crease C l i n i c ; and c e r t a i n l y wouldn't follow out their suggestions about coming to CGC so they could control her instead of vice versa. It i s clear i n Mary's case that there was l i t t l e opportunity to even attempt to work through Mary's resistance with her. The lack of integration of the d i f f e r e n t agency services stands out p a r t i c u l a r l y . Such lack of cooperative planning i s a r e a l hindrance to work with adolescents, and unfortunately happens a l l too often. Crease C l i n i c and the Child Guidance C l i n i c o r d i n a r i l y are i n closer touch with one another than was shown in t h i s case. However, similar i n c i -dents do happen with other community agencies and private physicians and p s y c h i a t r i s t s . Even when this type of fumbling is rare, i t c a l l s attention to the need for a concerted drive for integration of a l l f a c i l i t i e s needed by children of t h i s age. Only through a closer k n i t t i n g of purposes and methods w i l l the i n d i v i d u a l adolescent benefit f u l l y from the resources set up to serve him. Penny was referr e d by the school with threats of expulsion. Penny, a 13 year old g i r l , was described as " r e b e l l i o u s " . The school p r i n c i p l e wanted "action" taken 59 immediately due to the " i n t o l e r a b l e " influence Penny had on the other students. Prom reading her daughter's diary, Mrs. Cross believed Penny to be involved in sexual a c t i v i t i e s as well. Penny was an adopted c h i l d , and both parents thought her behaviour was the result of heredity. As might be expected, Penny showed very high resistance throughout her contact with the c l i n i c . Termination was abrupt, when Penny's parents sent her away to boarding school with no advance notice to either Penny or the c l i n i c . Previous to t h i s , however, Penny had cancelled a number of appointments and missed others with no excuses tendered. Throughout, Penny saw the whole problem as the adults i n her environment. The parents on the other hand wanted "something done about the g i r l " and likewise took no r e s p o n s i b i l i t y for change upon their shoulders. These concurrent attitudes did not f a c i l i t a t e a cooperative working rel a t i o n s h i p with the c l i n i c s t a f f . Each side, the c h i l d and the adults, attempted to use the c l i n i c to change the other h a l f . Here, we see the need for Interpretation of children's needs and the c l i n i c purpose, both i n d i v i d u a l l y and en masse. Certainly the hostile attitude of her parents and the school p r i n c i p a l would do l i t t l e to encourage Penny to expect understanding assistance from the c l i n i c . [ Decreasing Resistance The group of adolescents showing a decreasing degree of resistance ovir their c l i n i c contact i s a l l too small. However, perhaps we can learn from these youngsters that i t requires an opportunity to r e a l l y externalize the resistancd 60 ' and work with i t i f such a pattern i s to emerge. John, 13, was referred d i r e c t l y by the Juvenile Court. He had been charged with breaking and entering, stealing from milk bottles and general a n t i - s o c i a l , agressive behaviour. John began interviews with obvious resentment--talking i n monosyllables. He missed his next appointment and when the. worker v i s i t e d the home, John managed to elude the worker completely. He was then very late for his next appointment / but attempted to prolong i t . After missing another appoint-ment, the worker made arrangements to pick John up at home each week. John was able to express his feelings about coming i n . He didn't want to I After expressing his negative feelings about the c l i n i c , John began coming early for his appointments for a b r i e f period. He then reverted to his old pattern of la t e appointments and evasion of the worker. John's mother began with a f a i r l y cooperative attitude towards tie c l i n i c , hut the father was i n d i f f e r e n t . John was the i l l e g i t i m a t e c h i l d of his mother. She had married when John was one, to give the c h i l d a fatfae r . She l a t e r divorced t h i s man and married John's father. This marriage was most unhappy. There was such physical abuse of the mother that John was forced into a protective role at a young age. Unfortunately a l l three members of the family were seen by the same worker, and John i d e n t i f i e d the c l i n i c with his r e j e c t i n g father. He voiced his impression that he was coming to the c l i n i c because this was his father's wish. Although John Is s t i l l showing ambivalence and some resistance to casework, he i s continuing treatment and seems 61 to be involving himself i n the casework process. The pertinent f a c t i n this example i s that John was given the opportunity to verbalize his negative feelings about coming to the c l i n i c and i t seemed that these verbalizations drained o f f much of the energy that might otherwise have been channeled, into f l i g h t from treatment. Also the fact that the worker was "aggressive" i n going out after John and stated his expectation that John should keep appointments are large factors i n John's s i t u a t i o n . Many adolescents require this kind of pressure i n order to continue treatment. To leave the t o t a l choice of accepting.or r e j e c t i n g treatment up to the teen-age c l i e n t i s not too d i f f e r e n t to that of asking an infant for his opinion of adoptive parents. In neither instance have the c l i e n t s the needed knowledge and experience to make such a large decision. I f a youngster can benefit from treatment; i f he i s able to form a rel a t i o n s h i p and r e a l l y involve himself In the solution of his problem, then we must take the i n i t i a t i v e i n helping him to get the help he needs. Resume The manner i n which the Indivfiual's resistance entered into his use of c l i n i c resources can be seen from the i l l u s t r a t i o n s given in this chapter. There can be no doubt that the resistance of these t h i r t y adolescents was a serious impediment to t h e i r needed treatment. But to acknowledge th i s fact does not mitigate the s t i t u a t i o n . One must understand the underlying causes of thi s blocking of treatment. The answer does not l i e i n the source of r e f e r r a l or the present stimulus the adolescent has to seek treatment. There i s 62 s o m e t h i n g d e e p e r t o a c c o u n t f o r s u c h d i s p l a y s o f r e s i s t a n c e t o c a s e w o r k t r e a t m e n t . A r m e d w i t h some u n d e r s t a n d i n g o f t h e a d o l e s c e n t ' s l i f e p r o b l e m s , we w i l l a t t e m p t t o a n a l y z e t h e r o l e t h i s p l a y s i n h i s u s e o f c a s e w o r k r e s o u r c e s . I l l UNDERLYING RESISTANCE - WHAT? The resistance shown by the t h i r t y adolescents In thi s study cannot be attributed to one sole cause. Rather, i t i s a combination of factors in the present and past experience of the ind i v i d u a l c h i l d that l i e s behind his manifest resistance to casework treatment. As no two adolescents showed, exactly the same pattern of resistance during t h e i r contact with the c l i n i c , s i m i l a r l y , no two adolescents showed exactly the same reason for this resistance. Causes Underlying Resistance However, general causes of resistance were noted, among the t h i r t y children studied. For purposes of c l a r i t y , the writer has made fi v e major diagnosis of the resistance shown by these adolescent c l i e n t s . Eight of the adolescents showed d e f i n i t e t r a i t s of emancipation i n their withdrawal from, or resistance to c l i n i c treatment. Another nine showed d e f i n i t e oedipal attachments to parents which interfered with their p a r t i c i p a t i o n i n c l i n i c interviews for ind i v i d u a l reasons. Seven adolescents showed a combination of these two f a c t o r s -emancipation and oedipal attachment—which resulted i n extreme resistance to CGC treatment. Three adolescents could d e f i n i t e l y be c l a s s i f i e d as unable to form close relationships and three more combined th i s i n a b i l i t y to re l a t e with e f f o r t s to emancipate themselves from dependent r o l e s . The frequency of these under-lying reasons for resistance can be seen i n figure 7, page 64. 64 Figure 7: Frequency of Underlying Reasons for Resistance Legend Emancipation 60% ) Emancipation & . ) Oedipal (25 l/3#) ) Emancipation & ) I n a b i l i t y to ) Relate (10^ Oedipal 50% I n a b i l i t y to Relate 10% 65 Perhaps i n a b i l i t y to relate '.is the most s t r i k i n g factor In resistance. It i s d e f i n i t e l y unsound for any caseworker to expect whole hearted p a r t i c i p a t i o n from a c h i l d so warped by lack of close continuous relationships i n his early years that he can r e l a t e on a s u p e r f i c i a l l e v e l only. F e l i x P. Biestek-1- regards the client-worker r e l a t i o n -ship as the "soul" of casework. No caseworker, however s k i l l e d , can Impart this basic a b i l i t y to r e l a t e to his c l i e n t s . Resistance and Presenting Problem Compared In some c l a s s i f i c a t i o n s of resistance, a clue to the probable reason for resistance i s given i n the i n i t i a l problem stated by the c l i e n t or source of r e f e r r a l . It must be emphasized that t h i s diagnosis of resistance i s not a diagnosis of the presenting problem of the adolescent c l i e n t nor a diagnosis of the presence of resistance; but rather an assessment of the reason for resistance as shown at CGC. In every case studied there was some r e a l d i f f i c u l t y i n parent-c h i l d r elationship and often this struggle between two generations was projected upon the c l i n i c program and conse-quently interfered i n a r e a l way with the progress i n the c l i e n t ' s solution of the problem. In comparing the diagnosis of resistance with the presenting problems of these t h i r t y adolescents, Figure 8, page 66, indicates that the closest relationship Is between - LBiestek, F e l i x P.; "An Analysis of the Casework Relationship", Social Casework, February, 1954. 66 Figure 8: Relationship of Cause of Resistance  to Presenting Problem Oedipal I n a b i l i t y to Relate 55 l/5$ 66 2/5% 67 emancipation and i n a b i l i t y to relate with the presenting problem (100$). The relat i o n s h i p between the other causes of resistance and the presenting problem are thus: emanci-pation, 87|-$; I n a b i l i t y to r e l a t e , 66 2/3%; emancipation and oedipal, 59$; and oedipal, 33$. The relationship between the presenting problem and the reason underlying resistance i n the i n d i v i d u a l adolescent can be seen i n Appendix C. The three children who combined an i n a b i l i t y to rel a t e with e f f o r t s towards emancipation showed varied presenting problems, but ones which r e f l e c t e d a lack of s a t i s f a c t i o n i n close personal r e l a t i o n s h i p s . George, 13, was backward i n school, prone to accidents and jealous of his s i b l i n g s . G l o r i a , 14, was involved i n promiscuous behaviour and typed a s a l c o h o l i c . Joan, who came i n herself, suffered from severe anxiety and had withdrawn from i n t e r -personal r e l a t i o n s h i p s . Pour of the adolescents, i n whom emancipatory e f f o r t s played the most v i t a l part In their resistance, were brought i n by parents because of their r e b e l l i o u s behaviour which made parental d i s c i p l i n e d i f f i c u l t . One g i r l made personal application to the c l i n i c because she "couldn't stand on her own feet " . One g i r l was described as "untrustworthy" by her mother and the g i r l herself complained of her mother's d i s t r u s t . Another c h i l d was described a s f e a r f u l of growing up, unhappy and h o s t i l e towards others. Although fear of growing up does not seem l i k e an indicati o n of emancipation, we must remember that the problem i s described by the mother. It may be kept i n mind that possibly i t Is 68 the mother who fears the g i r l ' s adulthood. The cases of r e b e l l i o n , appear to t h i s writer,to be an in d i c a t i o n of natural adolescent e f f o r t s towards adult independence, which are perhaps exaggerated because of the intense struggle such e f f o r t s arouse i n an unhealthy family s i t u a t i o n . Of the three children showing i n a b i l i t y to r e l a t e , a l l three were brought i n on charges of s t e a l i n g . Deprived children, such as June, Grace and Wilma, often show symptoms of disturbance i n just such behaviour. Given no s a t i s f a c t i o n i n inter-personal relationships, they turn to other things for substitute g r a t i f i c a t i o n . Having no r e a l l y developed value system, th e i r stealing does not arouse the same anxiety and g u i l t that i t would i n a c h i l d with a s t r i c t e r super-ego structure. Of those youngsters showing a combination of oedipal attachment and emancipatory e f f o r t s underlying th e i r resistance, the complaints varied to a marked degree. Noreen, 16, showed disobedience and resentment towards her mother, which dated from her father's death. Mary, 13, was accused by her mother of aggravating her father. Doris showed physical symptoms with no organic basis. Both Graham and Danny were slow i n school. Danny showed aggressive behaviour; Graham had a poor r e l a t i o n -ship with women. L i l a , 13, was brought i n on complaints of theft and l y i n g . Diane,.16, was described by her mother as stubborn, uncooperative and unable to complete things. Of the nine adolescents showing unresolved oedipal i n attachments to parents; two d e f i n i t e l y indicated t h i s is/the i n i t i a l problem. Both Ann and Roxie were members of families 69 In which a second marriage had been entered int o . In Roxie's case, the problem was "a threat to the marriage". In Ann's case, the problem was "jealousy towards the second wife". The other seven youngsters showed no such obvious relationship between t h e i r presenting problems and the underlying causes of t h e i r resistance; although the fa c t that the majority of the complaints came from parents of the same sex may be s i g n i f i c a n t . There were two cases of acting-out behaviour and delinquent tendencies. Two were more s u p e r f i c i a l l y r e l a t e d to emancipatory e f f o r t s ; which of course Is part of the r e s o l u t i o n of such an oedipal attachment. In Thelma's case, the mother's banishment of her daughter from the home appears more clos e l y related to the reasons for her resistance than the other six problems c i t e d . Doubtless a l l these presenting problems can be linked up with the cause of resistance i f analyzed f u l l y enough. However, this i s not the purpose of this paper. The main premise i s the fact that resistance does occur for some reason. When resistance to treatment causes 23 children, badly i n need of help, to withdraw completely from that help, we must know why i f we are to extend services e f f e c t i v e l y to these youngsters. The writer i s therefore a r t i f i c i a l l y Ignoring the basic problems of these adolescents for the moment, and concentrating on the resistance shown and the reasons behind such behaviour. Although the Child Guidance C l i n i c i s not set up to deal primarily with resistance, when this i s present i t must be worked with f i r s t so that treatment can proceed. 70 I n a b i l i t y to Relate Perhaps i n a b i l i t y to r e l a t e i s the easiest factor to diagnose and the hardest to overcome of a l l these cate-gories. There are always forewarnings of this i n a b i l i t y to rela t e i n the case h i s t o r i e s of youngsters brought to the c l i n i c . In the three cases i n which th i s i n a b i l i t y to rela t e was of prime Importance i n the resistance of the adolescent to casework treatment; the g i r l s did have some sort of mother-child r e l a t i o n s h i p i n the f i r s t year of l i f e . We can assume from t h i s that t h e i r a b i l i t y to r e l a t e was not e n t i r e l y l o s t , but presently r e s t r i c t e d . Grace, 13, was 9 when her mother died, he s i s t e r 6. The two g i r l s were made wards of the Children's Aid Society following the mother's death. L i t t l e i s known of Grace's l i f e before this time. However, there is ample information regarding unsuccessful foster home placements and replace-ments to explain Grace's i n a b i l i t y to form a close r e l a t i o n -ship with her caseworker. She and her s i s t e r were placed i n the Children's Aid Receiving Home following t h e i r mother's death.. Both g i r l s were described,at this time, as sad and anxious and Craving attention. Grace was placed i n a foster home with her s i s t e r when she was ten. The foster mother l a t e r asked for t h e i r removal because the younger s i s t e r paid too much attention to the foster father! Grace was removed from t h i s second foster home because of the overt r i v a l r y with her s i s t e r . While i n her t h i r d foster home, Grace was described as " s e l f i s h , demanding, and babyish". She claimed she didn't want to grow u 71 up. When she was 12, Grace asked for an adoptive home. She was placed in a fourth foster home at thi s time i n which there were three other childrem two boys 10 and 6, and a g i r l 2. Grace continuously asked these foster parents to adopt her. She was most attentive to the foster father and would do any-thing he asked her. She was most upset i f he scolded her. She sulked i f the foster mother checked her on anything. Grace was l a t e r removed from this home and placed with an older couple who had a 12 year old daughter. The foster father was i l l a great deal and hospitalized. The foster mother was reputed for c o l l e c t i n g "strays". Grace seemed to f e e l quite at home i n this family and expected to be treated as one of them. But she was notJ The family went on a t r i p and returned Grace to the Receiving Home, following t h i s , Grace" began to deny any d i f f i c u l t i e s whatever. She returned to the foster home but ter security had already been shaken. Her only defense against further r e j e c t i o n was de n i a l . This she maintained stoutly. Her i n a b i l i t y - t o draw close to the worker seemed to be the r e s u l t of her pervading fear of further r e j e c t i o n . Although she had parti c i p a t e d quite f u l l y previous to this l a s t move, i t had always been on a surface l e v e l . Even this subsided following her recognition that she r e a l l y wasn't part of the foster family. Grace was further handicapped by her slow normal i n t e l l i g e n c e . • Wilma's. i l l e g i t i m a t e b i r t h and l i f e with various r e l a t i v e s has been described previously. The c l i n i c found that Wilma had experienced only s u p e r f i c i a l relationships and was hos t i l e towards women. She seemed anxious and 72 Immature with a low emtional capacity, but high average i n t e l l i g e n c e . She was frightened to death by any close r e l a t i o n s h i p and maintained that she must be responsible for her own actions. She could not depend, on anyS'ne. She was suspicious of anyone who took any interest i n her. Wilma trans-ferred her experience with her aunt's "pretended kindness" to other sit u a t i o n s . During her contact with the agency, she was i n four foster homes. None were satis f a c t o r y , for obvious reasons, and i t was f i n a l l y recognized that Wilma needed an impersonal therapeutic setting and plans were i n i t i a t e d towards th i s end. June, 15, remained with her mother except for a two year placement when she was 4-g- i n a s t r i c t private school. Her father had been in a nursing home for 11 years and so June had l i t t l e r e c o l l e c t i o n of him. She represented her father as dead i n the school records. Her mother had been t o t a l l y r e j e c t i n g of June. In the beginning of her pregnancy, Mrs. Sykes had attempted an abortion. She had a poor re l a t i o n s h i p with her husband, and i n fact l e f t him while she was pregnant with June. Mrs. Sykes had one i l l e g i t i m a t e c h i l d older than June. June's shop l i f t i n g and s t e a l i n g reminded Mrs. Sykes of her own mistakes.• June resembled her father and represented to Mrs. Sykes, the one t i e her husband had on her. June "clammed up" following her f i r s t interview, but i n s i s t e d that she wouldn't come to the c l i n i c i f she didn't get anything out of her interviews and continued her appointments. The diagnostic assessment of June indicated confusion around heterosexual r e l a t i o n s and g u i l t and anxiety about sex. She lacked a normal father figure and f e l t 73 inadequate and unloved. She was of mid-average i n t e l l i g e n c e . When the worker showed genuine interest and concern for her, June d i d not know how to act. She displayed the behaviour of a c h i l d wanting help, but not knowing how to react when the help was offered. Following a change of schools, June indicated a move to withdraw completely from c l i n i c help. I n a b i l i t y to Relate and Emancipation Joan 1 s^Lnability to rel a t e to the casewaker, coupled with her emancipatory e f f o r t s , led to a termination of casework interviews by the caseworker. It was Joan who i n i t i a t e d the contact. She sought r e l i e f from her severe anxiety. The c l i n i c p s y c h i a t r i s t noted schizoid tendencies i n his examination of Joan and advised against introspection. When the worker "withheld the answer", Joan responded to her as she had to her own mother who had not given her the care and af f e c t i o n she f e l t she should have received. When Joan was four, her father died, and she l i t e r a l l y l o s t her mother at t h i s time too. The mother l e f t Joan with her paternal grand-parents snd an aunt. When Joan was 16, her mother r e a l i z e d that these r e l a t i v e s were attempting to alienate Joan from her. She removed Joan from th e i r ca^re and put her i n a boarding house. Joan had many fantasies about her father, remembering him as an indulgent, affectionate parent. Probably Joan's memories of her father were encouraged and enhanced by his r e l a t i v e s with whom she l i v e d for 12 years. When she feegan casework, Joan was ambivalent towards treatment. She attempted to talk of her relat i o n s h i p with her father 74 rather than that with her mother. Probably the r e l a t i o n s h i p with her father was just as r e a l to Joan as was her r e l a t i o n -ship with her mother; for her contacts with the l a t t e r had been very few. JOSJI refused to go through the complete diagnostic examination. She was seen by a p s y c h i a t r i s t , however, who f e l t she should be discouraged from indulging i n introspection. Joan acted, out her h o s t i l i t y to her mother with the female caseworker and tended to lapse into fantasy about her father. The worker, f e e l i n g that these interviews were more destructive to Joan than constructive, terminated. Joan was f e a r f u l that her mother might become dependent on her. Perhaps she also feared her own dependency on her mother. Her passive attitude towards the future and towards treatment was her method of punishing her mother and the caseworker, who had become a mother-substitute. George, 13, was an i l l e g i t i m a t e c h i l d of mid-average i n t e l l i g e n c e , who had spent his f i r s t two years i n a.series of boarding homes. He ss.w his mother only once a month during this period. His mother married when George was two, to give the boy a home; but she was forced to work so George was cared for by a "series of housekeepers, and for a period by his step-father. There was a c h i l d of this marriage; a g i r l 3 years younger than George. The competition between the two children was keen, and George was always compared unfavourably to his s i s t e r . The step father was never well and spent much of his time i n a. nursing home. He resented, and rejected the boy and never contributed to his care f i n a n c i a l l y . George's mother also reflected the boy. Motherhood had been thrust upon her and she was unable to meet i t s challenge. With a deprived 75 infancy and subsequent r e j e c t i o n , George needed to deny his need for a f f e c t i o n a l r e l a t i o n s h i p s . With this denial, George was unable to enter into any sort of relationship with his worker except on a very s u p e r f i c i a l l e v e l . George was also trying to escape his mother's nagging and c o n t r o l . While : he appreciated his mother's d i f f i c u l t i e s , he resented her attempts to r e s t r i c t his behaviour. The c l i n i c seemed yet another attempt by his mother to control him, and George reb e l l e d . Emancipation Sheila, 16, was brought to the c l i n i c on an "emergency" basis by her mother who complained that Sheila was insolent, disobedient and refused to work around the house. Her mother was also bothered by Sheila's r e f u s a l to return to school i n the f a l l . Mrs. Purnie had been to the Family Welfare Bureau with t h i s d i f f i c u l t y , but receiving no quick solution, turned to CGC. Sheila complained that her mother was r e s t r i c -t i v e and was divulging a l l her personal a f f a i r s to others, ( f i r s t the Family Welfare Bureau and now CGCJ) She seemed ho s t i l e toward everyone and had a negative male concept. Sheila was i n the slow group of normal i n t e l l i g e n c e . She appeared to desire a better relationship with her mother, but since they could not agree, she apparently had decided she would rather not see her mother than disagree with her. Sheila d i d not view her mother's idea of CGC help kindly. When she refused to keep her f i r s t c l i n i c appointment, her mother l i t e r a l l y forced the g i r l to attend. 76 Although she was brought i n against her w i l l , Sfeila p a r t i c i p a t e d quite f r e e l y when she sensed the worker's understanding. Throughout her c l i n i c contact, Sheila seemed to l i k e being coaxed by the worker and she demanded the worker's constant avowal that she r e a l l y wanted to see and help Sheila. This beginning rela t i o n s h i p with her worker was not enough, however, to overcome Sheila's knowledge that her mother was coercing her into c l i n i c attendance. When Sheila refused to keep her appointments, to test her mother, Mrs. Furney would c a l l the Juvenile Court i n an e f f o r t to get them to force Sheila to attend. With this constant use of authority by the mother, the c l i n i c became just one more area i n which Sheila's frustrated fight for independence from her mother's domination became centered. Sheila's "do nothing" negativism towards the c l i n i c seemed to be an attempt to punish her mother and prove to Mrs. Furney that she could not force her daughter to p a r t i c i p a t e . She was so caught up i n this struggle with her mother, that she was unable to enter into the c l i n i c program f u l l y enough to see the help that was available here to support her i n her desire for independence. Instead, Sheila used her c l i n i c appointments as a test against her mother's control over hes. Si m i l a r l y with Sandra, the c l i n i c became her medium for achieving independence from her mother. Mrs. Kelsey used the c l i n i c as a threat to Sandra, who was running away from home, was truant from school and resentf u l of authority. When Sandra, a g i r l of bright normal i n t e l l i g e n c e , came to the c l i n i c , the Juvenile Court was already involved as Sandra 77 had run away from home several, times for a period of one or two days. Sandra exhibited fantasy tendencies and withdrawal from personal relationships at this time. She also lacked an adequate male concept. Sandra's f e e l i n g that she was un-loved was not without some basis. She was born 11 months before her father's death. He had been 111 for fi v e years, and was not expected to l i v e . Quite naturally, Mrs. Kelsey was unable to wholly welcome a child, at this time of c r i s i s . Sandra's t e r r i f i c need to be independent showed up i n her. c l i n i c contacts. She could not accept any kind of treat from her worker and payed her own, and often the worker's way, on any sort of outing. Sandra was unable to express any negative feelings about her mother or her home l i f e , a l -though, during the c l i n i c contact, Mrs. Kelsey sent Sandra to a very s t r i c t convent. Although Sandra, had to go to the convent, she"did not have to attend the c l i n i c . This was one area i n which she could prove to her mother that she did and would have some say over her own plans. Dorothy also claimed that her mother was talking about her behind her back. She resented her mother's application for CGC help. Dorothy took the attitude that i f she was unhappy and hated people, i t was her own business. The worker had to g i s i t the home to hold the i n i t i a l interview with Dorothy. At this time, Dorothy was very defensive. Mrs. Mannly admitted that she had always been a f r a i d of her daughter. She was an anxious, dependent woman, herself, who sought and accepted d i r e c t i o n . Her own feelings of inadequacy, were enhanced when her husband l e f t her shortly after she adopted Dorothy at his 78 suggestion. Dorothy's i l l - d i s g u i s e d contempt for her mother with her past divorce and menial work history, added nothing to Mrs. Mannly's regard for her s e l f . Dorothy's evasion df c l i n i c appointments was another source of embarrassment to her mother. Dorothy's s a d i s t i c need to hurt people and her h o s t i l i t y towards men, was one of the conclusions of the diagnostic conference. Her only s a t i s f a c t i o n seemed to l i e i n her i n t e l l e c t u a l achievements (she was of superior i n t e l l i g e n c e ) . Following the diagnostic evaluation, Dorothy happily reached a solution regarding her c l i n i c contacts. She decided to continue, seeing her own worker, but would not come to the c l i n i c for her appointments. The c l i n i c seemed to represent her mother's idea, whereas Dorothy could regard the worker, personally, as her own. In this way she was able to use casework help without l o s i n g her "independence". In a l l thr"ee cases, Sheila, Sandra and Dorothy, a very poor rela t i o n s h i p had developed,over the years, between mother and daughter. This probably contributed to the rebe l l i o u s and negative reaction of the g i r l ' s to t h e i r parents'' move towards c l i n i c help. Frances' personal application to the c l i n i c because "she was unable to s t i c k up for herself or stand on her own feet" enabled her to par t i c i p a t e f u l l y at the beginning. However, her d i f f i c u l t y and fear of dependency, with which she i n i t i a l l y requested help, eventually interfered with her p a r t i c i p a t i o n in the c l i n i c program. She was so frightened by her dependent tendencies that she was unable to l e t herself 79 go long enough to develop any sort o f r e l a t i o n s h i p with the C a s e w o r k e r since to Prances t h i s represented dependency. An additional factor i n Prances' resistance was her family's opposition to c l i n i c help. This raised further c o n f l i c t i n Prances' mind. Furthermore, i n her i n i t i a l interview she indicated that her parents didn't understand her and that t h i s was the source of her present problems. The c l i n i c team found Prances to be n e u r o t i c a l l y disturbed. Possessed with high general i n t e l l i g e n c e , she was using i n t e l l e c t u a l i z a t i o n and v e r b a l i z a t i o n as defenses and although she was aware of her a f f e c t , she was unable to handle i t . She l i m i t e d her personal contacts i n an e f f o r t to repress her anxiety. Underneath, Prances had i n f a n t i l e expectations. She wished to be understood without e f f o r t on her part and took no r e s p o n s i b i l i t y to a l t e r her s i t u a t i o n . Her r e l a t i o n s h i p with the worker fluctuated between extreme i n f a n t i l e dependency and withdrawal from this p o s i t i o n . Edith, 15, stated frankly her determination to stand on her own f e e t . She did not want anyone to lean onl Her every action represented a flaunting of independence. In her own way, she t r i e d to make the worker dependent, on her. She would telephone to say she would be i n for her appointment and then not show up. She did this consistently for one month, always c a l l i n g the worker l a t e r to see i f she had managed to anger the worker. There was another two month period when Edith followed this same behaviour and voiced her intention of making the worker angry with her. At the same time, she informed the worker in a rather superior way that she was "working on her own problem". Edith's anxiety regarding male 80 and female i d e n t i f i c a t i o n and her tendency to inversion as seen i n her homosexual attachments to the school teacher and also to the worker; also entered into the t o t a l picture of resistance. She attempted to make the r e l a t i o n s h i p with the worker a personal one. She would telephone the worker In the company of her friends and re f e r to the worker i n terms of endearment. These passionate displays raised further anxiety that led to her avoidance of personal, interviews with the worker. Edith was extremely threatened b y l i v i n g alone with her father, whom she saw as a sexual object. The c l i n i c team saw the p o s s i b i l i t y of f r i g i d i t y or promiscuity a r i s i n g from t h i s l i v i n g arranganent. In no other group w i l l you f i n d a more enthusiastic bid for independence than i n the adolescent age group. With these youngsters i t Is " a l l or nothing at a l l " . Poorly equipped for the battle, they must be INDEPENDENTi Whereas the adult, who has resolved at least some of the t r i a l s and t r i b u l a t i o n s of this adolescent stage of l i f e , expects to be dependent on others i n many ways; the adolescent Is not yet secure enough i n himself to grant that dependency i n a healthy fashion is true of a l l people. While he Is striving to gain a modicum, of independence; he must narrow his focus down to this one thing. This i s so clear i n the andysis of the youngsters showing resistance due to the strength of their emancipatory drive. Anything that can be construed as depend-ence i s so frightening to this youngster, who i n so many ways is longing for a dependent re l a t i o n s h i p , but feels his development i s thwarted by such a r e l a t i o n s h i p — t h a t he w i l l 81 avoid any such s i t u a t i o n . The casework r e l a t i o n s h i p , i s necessarily a dependent one In this sense. Perhaps this alone i s enough to send the adolescent running. The less successful the adolescent has been i n his f i g h t for freedom, the more frightening such a rela t i o n s h i p w i l l be to him. We must therefore consider these factors i n working with any adolescent. These youngsters who have such a t e r r i f i c need to avoid any sort of dependency i n r e l a t i o n to another person, are not exhibiting only normal adolescent s t r i v i n g s to be independent. They are reacting, i n varying degrees, to their experience with parents. Often the main c h a r a c t e r i s t i c goal exhibited i n th e i r behaviour—both i n treatment and elsewhere--is that of proving that they "do not need anyone 1" To them, the only way of getting along i n l i f e Is to depend on themselves. Oedipal Attachment Among those youngsters showing oedipal attachments to parents which interfered with t h e i r c l i n i c p a r t i c i p a t i o n , was Thelma. She was f i n a l l y banished from her home by her mother due to continual f i g h t i n g and h o s t i l i t y towards her mother, her s i s t e r 15, and,her brother, 5. Thelma's father was away from home at the time. When she was small, Thelma had a strong, pos i t i v e r e l a t i o n s h i p with her father. As she got older, however, she took much physical abuse from him. S t i l l , Thelma maintained that she could forgive her father anything, because i t was only through her mother's insistance that he acted i n such a punitive manner. It was only her 82 mother she "hated". Mother pushed too much r e s p o n s i b i l i t y on Thelma. Thelma talked of her father as much l i k e h e r s e l f . She voiced her f e e l i n g that she was superior to her mother. In f a c t , she f e l t older than her mother; more of her father's ageJ Thelma spoke of the things she and her father would do when they were back together again. When this bubble burst, and Thelma received word that her father bad a l l i e d himself with her mother; she was crest f a l l e n . Her father had written to her t e l l i n g her he believed a l l her d i f f i c u l t i e s stemmed from s e l f p i t y and imagination. Thelma made a complete reversal from oolf p i t y and imagination. Thelma verbalized• her intention of not getting well; so she could prove her father wrong i n his estimate of her. The c l i n i c a l diagnosis noted the onset of paranoid schizophrenia i n this bright, i n t e l l i g e n t g i r l . Her i n a b i l i t y to accept her mother's r e a l r e j e c t i o n of her was one of her most obvious d i f f i c u l t i e s although she did have some insight into her anxiety and depression. John' s i l l e g i t i m a t e b i r t h , his mother's two marriages, the l a t t e r to his father, hage been recountedpreviously. The close relationship of mother and son was stimulated further by the marital discord; the father's physical abuse of his wife; and the r e j e c t i o n openly displayed by him to his son. John, age 13, was prematurely pushed into a role of protecting his mother from his father. Mrs. Owen recip r o -cated John's a f f e c t i o n overtly, but f e l t g u i l t y about t h i s . Mr. Owen increased his wife's g u i l t by accusing her of having more time and a f f e c t i o n for her son than for her husband. 83 One of John's basic d i f f i c u l t i e s was his fear of being a male c h i l d . He had no adequate father figure or masculine pattern with whom he could i d e n t i f y . To add to this pathology, John l o s t a toe In his pre-school years and s t i l l showed extreme concern about this mutil/ation. This probably added to his fear of being a" boy. On the other hand, John tested In the average group of general i n t e l l i g e n c e with superior p o t e n t i a l i t i e s and was able to relate on a more than super-f i c i a l l e v e l . A l l three members o f the family were seeing the same worker, a man. With John's experience with men and his fear that his father wanted to get him out of the home and away from his mother; the c l i n i c became t i e d up with t h i s c o n f l i c t . John i s s t i l l continuing treatment at the c l i n i c , but under the pressure.of his probation o f f i c e r , and with t h i s problem s t i l l not resolved. Loie, age 18, made her own r e f e r r a l . She complained that her motherw ould not l e t her be independent. Lois had considerable insight into her own problem. She evidenced some schizoid tendencies and an inadequate personality which stemmed from her environment and association with a neurotic mother. It was when she recognized that her dependence on her fiance* was a substitution for her wished for r e l a t i o n s h i p with her father, that she began to reslsb further treatment. Although, i n t e l l e c t u a l l y she gave.cognizance to t h i s s i t u -ation, she could not face breaking up with her boyfriend and i t was d i f f i c u l t to get any attention from her father. Part of L o i s ' avoidance of c l i n i c contact appeared t o stem from her g u i l t about being unable to break with her boy friend 84 afte r the worker had indicated that this would be the wisest thing. Wot only did Roxie's step mother regard her as a threat to her marriage; but Roxie's father also acted as though t h i s 1 2 year old of low i n t e l l i g e n c e , was his wife's r i v a l . His f i r s t wife had been promiscuous and caused a great deal of scandal i n the community when she became i l l e g i t i m a t e l y pregnant p r i o r to their divorce. To Mr. Ingles, Roxie represented the unpleasant memories of his f i r s t marriage. When Roxie's behaviour also began to reverberate i n the community, with her stealing and running away, Mr. Ingles became alarmed and sought outside help to cope with the d i f f i c u l t y . Although Mr. Ingles f e l t responsible f o r Roxie his f i r s t though was to preserve his mariiage. Mr. Ingles a c t u a l l y thought i t was his second, wife's attitude to Roxie that caused her d i f f i c u l t i e s ; but he was a f r a i d to make an issue of this i n ease It should endanger his marriage further. Roxie seemed overly concerned and g u i l t y about hetero-sexual r e l a t i o n s . Perhaps this was a r e f l e c t i o n of her father's fears that Roxie would carry out his f i r s t wife's behaviour. On the other hand, Roxie's surface desire to escape her step mother and her desire to break up the marriage may have contributed to t h i s anxiety. The c l i n i c ' s b e l i e f that Mrs. Ingle's complete r e j e c t i o n of the g i r l could not be modified led them to support the idea of foster home placement. Roxie's subsequent resistance seems to be rel a t e d to her determination to stay with her father. Her knowledge of the c l i n i c ' s p o sition undoubtedly led her to believe that the c l i n i c was an alien force in her f i g h t to remain with her father. 85 Sylvan Kaiser's presentation of a manifest oedipus complex i n an adolescent g i r l 1 appears to have general s i g n i f i c a n c e . In speaking of the therapeutic r e l a t i o n s h i p between himself and his f i f t e e n year old c l i e n t , he notes the t y p i c a l resistance which developed due to the sexualized transference. He further comments that i t was clear to him "that this patient could only have a sexualized r e l a t i o n s h i p . Either she became sexually involved or else she could have no contact with either male or female," 2The writer believes that t h i s i s generally so with these adolescents studied who were Involved i n oedipal relationships with their parents; and that t h i s i s the source of resistance to casework i n such youngsters. Referring further to Dr. Keiser's discussion of this case, he points out the importance of the fact that he d i d not see the g i r l ' s mother since the g i r l f e l t that once a man had seen her i r r e s i s t a b l e mother, he could no longer have any interest i n h e r s e l f . The writer does not purport that t h i s Is so In every case; but merely points out that i n deciding about the treatment plan, care should be taken, i n these instances where oedipal threads are <d iagnosed, that further r i v a l r y i s not engendered through the same worker seeing the parent and c h i l d . Emancipation and Oedipal Of the seven remaining youngsters, none of whom are continuing treatment, there are indications that emancipatory 1 K e i s e r , Sylvan, (M.D.); "A Manifest Oedipus Complex in ah Adolescent G i r l " , The Psychoanalytic Study of the C h i l d , VIII, 1955. 2 Ibid, p. 105. 86 e f f o r t s and oedipal attachments interfered with their use of clinfc services. Throughout her contact with the agency, Diane age '16, par t i c i p a t e d i n an inverse r e l a t i o n s h i p to that of her mother. While her mother was cooperative towards c l i n i c help, Diane was most r e s i s t a n t . As soon as her mother terminated contact with the c l i n i c , Diane showed interest i n continuing. Mrs. Wilson stated that Diane had been a d i f f i c u l t c h i l d from b i r t h . She described Diane as stubborn and uncooperative. Thee had been considerable marital f r i c t i o n i n the home for the past eight years. Diane had desperately t r i e d to gain her father's approval. However, Mr. Wilson paid l i t t l e attention to his daughter. He f e l t smothered by his wife and f e l t that she was unable to share him with anyone, including his daughter. Diane worshipped her dad. Her p o s i t i o n of r i v a l r y with her mother carr i e d over into the treatment s i t u a t i o n . The diagnostic assessment of Diane showed some indications of a frustrated attachment to her father. She was f e a r f u l of her aggressive feelings (towards her mother?); couldn't trust her own judgement or a b i l i t y to achieve, although she possessed high average i n t e l l i g e n c e ; and was f e a r f u l about completing things. The marital f r i c t i o n made i t necessary for Diane to deny her desire to exclude her mother since this might be accomplished a l l too r e a l i s t i c a l l y . Consequently she had been able to rel a t e to persons of her own sex only; The anxiety engendered by Diane's seeing the same worker as her mother, a woman, as some of her negative feelings came to the surface, made her anxious to escape treatment. 87 L i l a , age 13, used the cl i n i c to show her f i r s t r e b e l l i o n against her mother's c o n t r o l l i n g , self-righteous and punitive way of handling her daughter. Mrs. Debrisay f e l t that L i l a ' s l y i n g and stealing shouldn't happen after a l l she had s a c r i f i c e d for the c h i l d . She had just recently entered a new marriage to a professional man. Her feelings of incompetence i n this new role and her doubts about the success of her marriage, l e d her to project a l l her fears onto L i l a . She was unable to see her own role In L i l a ' s d i f f i c u l t i e s . In desperation about the si t u a t i o n , Mrs. Debrisay became more and more punitve towards L i l a . She used the c l i n i c i n her c h a r a c t e r i s t i c way and L i l a rebelled against her mother through her avoidance of c l i n i c contacts. Mrs. Debrisay had an unhappy f i r s t marriage. She was just 17 when she married L i l a ' s father, a boy of 19. L i l a was born a year l a t e r and her father took no r e s p o n s i b i l i t y for the family's support. Mrs. D&brisay f i n a l l y l e f t him when L i l a was 4. Her divorce and remarriage had not served to d issipate her c o n f l i c t i n g Seelings about her f i r s t husband. Mrs. Debrisay saw L i l a S3 "just l i k e her father" and L i l a ' s adoration of her own father, her fantasies about a l i f e with him--all played into Mrs. Debrisay's own c o n f l i c t . Mrs. Debrisay successfully blocked any discussion of her f i r s t marriage and her feelings about her f i r s t husband by missing appointments and bringing her second husband with her to interviews. Following the diagnostic examination, which showed L i l a to be r i g i d l y c o n t r o l l i n g her feelings; L i l a acted out her c o n f l i c t s about her mother^ and her conception 88 of her father. On one occasion she was found i n a motel i n the company of three older boys at midnight. Danny, age 12, was c e r t a i n l y involved i n a family t r i a n g l e . His. mother was very protective of him. The parents were involved in a. struggle for dominance, the father f e e l i n g i n f e r i o r due to his unsuccessful e f f o r t s i n this area. Danny had a very poor rela t i o n s h i p with his father who rejected the boy and viewed him as a r i v a l . Mp. Powell was most Impatient with his wife's over-protection of the boy. Danny was competing with his father for Mrs. Powell's attention. The fact that the c l i n i c worker attempted to see a l l three members of the family contributed to the boy's resistance to c l i n i c interviews. He verbalized his f e e l i n g that he was coming to the c l i n i c primarily because his father wanted him to. This was strike one against Danny's p a r t i c i p a t i o n i n c l i n i c . In addition, Mr. Powell continually attempted to usurp the boy's treatment time and Danny was very r e s e n t f u l of t h i s . Unless he was reminded by his mother, Danny "forgot" his appointments. Danny continually questioned the worker about how long he would, have to come to the c l i n i c . Several other factors Entered into this s i t u a t i o n . Danny was examined at Crease C l i n i c with l i t t l e preparation for t h i s due to administrative entanglements which separated Crease C l i n i c from CGC i n the i r planning. Danny endured some pain while at Crease C l i n i c . His resentment about this was directed towards CGC whom he regarded as responsible for this "punish-ment". The punitive attitude of his father seemed to be 89 repeated for Danny i n this experience. When Mr. Powell became i l l and was o f f work for some time, the gains the mother had made over the period of treat-ment were l o s t i n th i s c r i s i s and she returned to her former understanding of the s i t u a t i o n . Again, a mix-up i n regards to Danny's schooling entered into the o v e r - a l l resistance to treatment. The worker f e l t that his support of the school board's decision to transfer Danny to another school weakened his relat i o n s h i p with the family. A change i n workers seemed to be the l a s t straw for Danny. He held to his contention that i t was his father who made him come to c l i n i c . At the same time Danny r e a l i z e d that his father had never l i k e d him and was just waiting for an opportunity to get r i d of him. The parents' insistence that Danny's aggressive behaviour was the r e s u l t of his associations with "bad boys" was quickly picked up by Danny, and as a r e s u l t he was unable to take any r e s p o n s i b i l i t y for his d i f f i c u l t i e s . Danny tested i n the d u l l normal group of i n t e l l i g e n c e . Organic abnormalities were found. He lacked inner strength and had no value system. His expression of h o s t i l i t y was blocked by g u i l t f e e l i n g s . The worker f e l t that Danny was unable to accept further treatment un&il he became anxious enough to want to change, and i n view of the boy's resistance and the parents' lack of interest, reached a decision to close the case. Graham, age 13, was i n need of a continuing r e l a t i o n -ship with a man, according to the diagnostic assessment. Unfortunately,Danny suffered from the rapid turnover of 9 0 professional workers and was assigned to a series of d i f f e r e n t caseworkers. He had found i t d i f f i c u l t to i d e n t i f y with his own father, who was an inadequate person, dependent on his wife for adequate functioning. Mrs. Brawn played the rol e of mother to both husband and son. Graham was i n a ri v a l r o u s p o s i t i o n with his father and younger brother, age 6, who were preferred by his mother. Actually, Graham had received l i t t l e a f f e c t i o n or s a t i s f a c t i o n from either parent and was possessed of only slow general i n t e l l i g e n c e . Graham's negative r e l a t i o n s h i p with his mother, appeared to the writer to be his defense against the resurgence of oedipal wishes for his mdjther'3 a f f e c t i o n . Graham's father had never been able to express any negative feelings, and Graham became most anxious after his f i r s t show of h o s t i l i t y towards his worker. This display seemed to have a d i r e c t bearing on Graham's eventual withdrawal from c l i n i c help. Indications of his anxiety were shown when, following his f i r s t d i r e c t display of anger towards the worker, he was unable to return to the c l i n i c for his next appointment. He seemed to need to deny, at the same time, any p o s i t i v e f e e l i n g for his mother. He claimed he came to the c l i n i c to get away from "the old bitch", his mother. His mother made i t extremely d i f f i c u l t for Graham to break away from her by her extreme over-possessiveness and subtle seduction of the boy. Following each weekly interview, Graham displayed increasingly impudent behaviour at home. It was a major triumph for the second worker when Graham was able to agree to a change i n interviewing time that coincided with 91 the time his mother also wished him to come i n . Graham was consistently negative to anything that appeared to please his mother. Even when he did keep his appointnents with the worker, Graham hid behind airplane models and ether manual a c t i v i t i e s to avoid' any conversation with the worker. In the f i n a l analysis, Graham and his mother did come to an agreement. That was their f i n a l decision to terminate c l i n i c contact. Observations Each c h i l d i n this study showed ,. his:> own in d i v i d u a l reactions to c l i n i c treatment, i n keeping with his present l i f e s i t u a t i o n ; his past experience and the c o n f l i c t s i n which he was. engaged. "To review b r i e f l y some of the t y p i c a l c o n f l i c t s of adolescence, i t i s apparent that i n this phase of development, when the ego i s weak and the i n s t i n c t s strong, the basic c o n f l i c t s are polarized c h i e f l y around anxiety about authority and sex . . . . we know that with the i n -creased pressure exerted by the i n s t i n c t s at this period, greater defenses need to be.built up to control the anxiety generated." 1 It i s not so surprising then that the resistance seen i n these adolescents Is d i r e c t l y related to the c o n f l i c t s of this phase of development and the defenses erected to protect themselves from further damage. It i s a s i m p l i f i c a t i o n to put the onus of a l l adoescent resistance onto the c o n f l i c t s i n thi s stage of development. However, the adolescent's l i f e p o s i t i o n i n -'•Ellsworth, Dorothy; "Precocious Adolescence i n Wartime", Reprinted from The Family, March, 1944. which he i s trying to bridge the gap between childhood and adulthood does seem to enter into the treatment p i c t u r e . Every c h i l d c i t e d above, was Involved i n an unhealthy family p i c t u r e . His progress towards the goal of independence and emotional attachment outside of his immediate family c i r c l e , was i n some way thwarted by his family. The c l i n i c appeared to become a part of this same struggle rather than a menas of surmounting the s i t u a t i o n a l d i f f i c u l t i e s . Dr. Donald A. Bloch 1, considers delinquency as a mode of interpersonal Integration. He points out the import-ance of the c h a r a c t e r i s t i c ways parents use to avoid anxiety and achieve g r a t i f i c a t i o n as revealed i n the expectations that t h e i r children have of l i f e . These expectations, according to Dr. Bloch, correspond reughly to the super-ego, in that they represent the aggregate of parental i n t e r n a l i z e d q u a l i t i e s . This i s of importance when we meet adolescents whose goal i s to need no one i n l i f e . E s p e c i a l l y with the delinquent adolescent, this goal motivates their a n t i - s o c i a l behaviour i n ways that are geared to provoke r e j e c t i o n , deprivation and suffering which they experienced i n e a r l i e r l i f e experiences. Dr. Bloch points out that this provoking behaviour i s carried on mainly to avoid experiencing dangerous dependency needs. The defenses of the adolescent delinquent are aggressive h o s t i l i t y and f l i g h t . These defenses enter into the treatment s i t u a t i o n at CGC where the youngsters, delinquent or not, use th i s means of f l i g h t to avoid casework treatment. Not a l l the teen-agers r e s i s t i n g treatment are doing so primarily to avoid any sort of dependency r e l a t i o n s h i p . But many of them area ' 1 BToch,_ U . A . , ~%ome Concepts i n the Treatment of DeIln"qTIsm.ts (ehTldren/ March-April. 1954. 9 5 One of the main attacks on such behaviour i s adequate diagnosis of the degree of closeness i n relationship that such youngsters can tolerate. The delinquent group are. generally extremely resistant to thinking of themselves as needing help. Their s e l f perceptions do not allow for weakness or acceptance of anything from another person. Enforced intimacy may cause panic i n the delinquent. It i s this writer's opinion that a certain amount of resistance to treatment can be expected from the adolescent c h i l d who i s being blocked by his family i n his attempts to master the c o n f l i c t s of this age. The adolescent at any time is a delicate person to handle. The vwry struggles i n which he i s engaged are counter indications that he w i l l respond . spontaneously to treatment. Granting, then that resistance w i l l be an i n t e g r a l part of casework with adolescents with family d i f f i c u l t i e s super-imposed upon their normal struggles; do we have the means of helping the adolescent to use the treatment he needs? IV WORKING WITH RESISTANCE Restatement of iFoeus of the Study This study presumes only to deal with the resistance shown by the adolescents in Child Guidance Clinic treatment. No attempt has been made to assess the Beneficial results of their contact with the c l i n i c . The quality of casework done with these youngsters has been of a consistently high calibre. In a number of known cases, although the adolescent resisted treatment violently, he showed improvement in his behaviour and attitude towards l i f e following his termination of contact with the agency. A follow-up study on the results of casework done with this group of "resisting adolescents' would be of great value i f i t did no more than prove that i t is not a "lost cause" to seek to treat such a group of child-ren. Often a period of integration; from interview to inter-view, or from termination on; leades the youngster to reorganize his characteristic ways of looking at the world and to acquire a healthier orientation to his environment, although this may have been very obscure during his contact with the agency. It almost seems that these youngsters require a "period of digestion", on their own, to achieve and assimilate some of the very modifications and insights the caseworker was valiantly striving to impart to this young client during his c l i n i c contact. For this reason, i t seems to the writer to be a valid conclusion that not a l l adolescents, direly in need of help, can be allowed to take on the responsibility of deciding themselves whether or not they w i l l avail themselves of needed 95 services. An active role is required of the caseworker in "going out " to the adolescent client in an attempt to involve him in treatment* Experiments in New York, where repeated home v i s i t s have been made in the face of constant rejection have proved that symbolically this going out to the client is of value in ultimately involving the adolescent client in casework. Findings of the Present Study Adolescents, as a group, have d i f f i c u l t y in accepting any need, for help. They are so concerned with protecting their precarious sense of adequacy, that to admit weakness in any area is almost more than their weak egos can bear. As a consequence, i t is unusual for an adolescent to seek an adult's help in solving the dilemmas of this age. This has been borne out in this particular study, which involved thirty teen-agers who showed resistance to adult help in the Vancouver Child Guidance Clinic. Of the thirty youngsters, only three asked for help on their own i n i t i a t i v e . The others were brought in by pressure from other adults in the community. Seven of these youngsters came to the c l i n i c at the suggestion of others; three were pressured by other people to attend the c l i n i c ; eleven were referred by authoritative sources; and six were brought in under parental pressure. An attempt has been made here, to assess the stimulus, not the source of referral, leading to the adolescent's f i r s t contact with the Child Guidance Cl i n i c . The source of refer-r a l mayibe the same in two cases; but the individual's attitude towards this source of referral can be grossly different. 96 Thus, when we speak of authoritative r e f e r r a l s — i t may Indicate that the adolescent had no cholc@ i n the matter, or that he f e l t he had no choice i n the matter. A parental r e f e r r a l may be so regarded by the adolescent, and i f so, he i s Included i n this group. Again, a parent may be included i n that category of "parental pressure". In t h i s s i t u a t i o n , the r e f e r r a l i s a family matter, not necessarily an authoritative d i r e c t i o n , but the Idea i s d e f i n i t e l y that of the parents, not the adolescent. "Suggestion of others" indicates a cooperative decision to attend the c l i n i c , but d i f f e r s from the adolescent^ own i n i t i a t i v e , because he presumably has much less knowledge of the c l i n i c process than those who seek i t out on their own. "Pressure from others" indicates that the adolescent f i n a l l y "gave i n " to someone who saw the need for his treatment; but does not imply that he too saw this need for help. His decision to accept the r e f e r r a l may only be his appeasement of the person who has been pressuring him. F i n a l l y , those who sought treatment on t h e i r own i n i t i a t i v e are those who actually saw the need for help, themselves, and sought i t out on their own. The majority of adolescents, i n this group of t h i r t y , began their c l i n i c contact with some degree 'of reservation. The work done with these youngsters at the time of their i n i t i a l contact i s v i t a l l y important, because roots of resistance may be detected and worked through. The experience G&ey have at t h i s time may be a turning point i n the adoles-cent ' s attitude to treatment. The patterns of resistance i n this group is s i g n i f i c a n t i n planning casework with adolescents. By far the largest 97 group, 50$, showed a p r o g r e s s i v e 'degree o f resistance^ through-out t h e i r c l i n i c c o n t a c t . P o s s i b l y seeds of t h e i r t e r m i n a l r e s i s t a n c e was present i n i t i a l l y , but undetected. For one reason or another, t h e i r experiences i n casework d i d not serve t o overcome t h e i r r e s i s t a n c e s to treatment. The v a l u e of c o n t a c t w i t h the c l i n i c , was not s u f f i c i e n t l y absorbed,by these a d o l e s c e n t s , to overcome the dynamic b a s i s of t h e i r r e s i s t a n c e . The i n t e r e s t i n g f a c t i s t h i s : v e r y few of t h i s group showed much r e s i s t a n c e to treatment I n i t i a l l y , whereas the group who showed, a d e c r e a s i n g degree of r e s i s t a n c e throughout t h e i r c l i n i c c o ntact (13.l/s$) showed c o n s i d e r a b l e r e s i s t a n c e at f i r s t . There are many p o s s i b l e e x p l a n a t i o n s f o r t h i s , but i t seems to the w r i t e r t h a t t h i s f a c t may i n d i c a t e t h a t the work w i t h t h i s smaller group was geared from the f i r s t to handle t h e i r r e s i s t a n c e , whereas i n the l a r g e r group i t was not r e c o g n i z e d as a severe problem. Perhaps i f we began a l l c o n t a c t s w i t h adolescents by e x p e c t i n g and l o o k i n g f o r r e s i s t a n c e , we c o u l d t u r n t h i s group who showed i n c r e a s i n g r e s i s t a n c e i n t o one i n which r e s i s t a n c e was decreased. The caseworker can do a great d e a l to help t h i s group use c l i n i c s e r v i c e s , but she cannot combat a l l the c o n f l i c t s of adolescence which enter i n t o t h i s m a n i f e s t a t i o n o f r e s i s t -ance. We must face the f a c t t h a t adolescents are an extremely d i f f i c u l t , i f c h a l l e n g i n g , group to work w i t h . In some of the cases s t u d i e d , there were some elements i n the casework i t s e l f , t h a t c o u l d have been improved i n order to f a c i l i t a t e the a d o l e s c e n t ' s use of c l i n i c s e r v i c e s . These d e a l t mainly w i t h changes i n workers and adolescents who needed 98 a worker separate from their parents due to r i v a l r y and int e n s i t y of emancipatory e f f o r t s with th e i r family. However, the most s t r i k i n g fact is t h i s : the primary cause of resistance i n 60% of these children was t i e d up with their emancipatory drives, quite apart from the casework done with these youngsters. In fact, i f the casework had not been so s k i l l f u l , many of these youngsters might have l e f t treatment much sooner than they did._ Another 30%' were hindered i n th e i r use of treatment by unresolved oedipal f i x a t i o n s to parents'; and an additional group of 10% were unable to enter into a relat i o n s h i p with their worker, which i s a primary requisite for treJt ment. The Caseworker One e s s e n t i a l partner in this work has been neglected throughout t h i s discussion. The caseworker, who works with adolescents, has tremendous demands made of her. Most people i n the s o c i a l work f i e l d are in this profession because they have some need to help others. 1 But t y p i c a l l y , the adolescent professes to dispense with this help. Resistances of c l i e n t s are often anxiety provoking to workers and this i s p a r t i c u l a r l y so when an adolescent i s involved. This age has been regarded by workers as a new chance for a c h i l d to achieve a more healthy integration both within himself and with his environment. Trends towards delinquency, neuroticism and psychotic behaviour i s obvious to the s k i l l e d worker who i s 1Bloch, Donald A (M.D.),'in his a r t i c l e : "Some Concepts i n the Treatment of Delinquency", Children, March-April, 1954, speaks of this "need to help" i n mental hygiene workers (including s o c i a l wDDkers) as stemming from a desire to get help with one's own problems, p. 53. 99 dealing day after day with youngsters i n t h e i r teens. It i s only natural that the worker w i l l try to prevent such trends from developing f u l l y . F a i l i n g i n this attempt is l i k e l y to be upsetting to the most mature person. Whitaker and Malone 1 speak of the role of anxiety in psychiatric treatment. In this writer's opinion, their discussion and c l a s s i f i c a t i o n i s applicable to casework, also. "Anxiety, to the authors, represents the most primitive form which a f f e c t , or f e e l i n g can take i n the human being. As such, anxiety represents unorganized affect . . . » The structuring of personality occurs around the organization of af f e c t (anxiety). . . . In the adult, anxiety as defined above arises whenever) the organization of affect i n the i n d i v i d u a l breaks down, i»e., whenever his ego breaks down."2 Their premise i s that anxiety i n both the worker and the c l i e n t i s necessary i f any movement towards treatment goals i s to occur. However, they point out that there are at least two kinds of anxiety. One, negative anxiety, i s "associated with a breakdown of the patient's or therapist's defenses (and) usually antecedes positive anxiety associated with the onset of a more healthy organization of a f f e c t within the matrix of this r e l a t i o n s h i p . " ^ The anxiety of the mature therapist has p o s i t i v e aims. Having worked through most of his gross pathology, he seeks better integration -and organi-zation of his own affect intrpersonally through his relationship with each patient. He has anxiety commensurate with his i n t u i t i o n of the p o t e n t i a l depth of the interpersonal •'•Whitaker and Malone; Roots of Psychotherapy, 1955, p>123 gQp-. c i t . 50p. c i t . 100 r e l a t i o n s h i p w i t h a p a r t i c u l a r p a t i e n t . This presages growth f o r him. " . . . The growing pains are the a n x i e t y * The r e s o l u t i o n of the a n x i e t y , whether ne g a t i v e or p o s i t i v e , r e f l e c t s s u c c e s s f u l growth and b e t t e r I n t e g r a t i o n i n e i t h e r or both p a r t i c i p a n t s . " 1 P o s i t i v e a n x i e t y r e f l e c t s the worker's or c l i e n t ' s a n t i c i p a t i o n of betterj&ient. That i s , goals o f treatment are seen by one or both p a r t i c i p a n t s , and the an x i e t y i s d i r e c t e d towards the accomplishment o f t h i s g o a l . Negative a n x i e t y i s o f a more p e r s o n a l n a t u r e . T h i s means that the defenses of e i t h e r the c l i e n t or the worker are th r e a t e n e d by the m a t e r i a l d i s c u s s e d or the r e l a t i o n s h i p w i t h i t s elements of t r a n s f e r e n c e and c o u n t e r - t r a n s f e r e n c e . In t h i s event, 'the a n x i e t y i s r e l a t e d to p e r s o n a l c o n f l i c t and the r e s o l u t i o n o f such a n x i e t y , i n the worker, has l i t t l e to do w i t h the t h e r a p e u t i c g o a l , and may be d e s t r u c t i v e to the p r o f e s s i o n a l r e l a t i o n s h i p . In c o n t r a s t to ne g a t i v e a n x i e t y , which a r i s e s out o f psychopathology, p o s t i v j l e a n x i e t y occurs i n an i n d i v i d u a l who f i n d s h i m s e l f i n an i n t e r p e r s o n a l r e l a t i o n s h i p w i t h i n the mat r i x I o f which he p e r c e i v e s the p o s s i b i l i t y o f b e t t e r o r g a n i z i n g h i s a f f e c t (growing). In , these Instances, new and unorganized a f f e c t becomes m o b i l i z e d f o r growth. Thus the m o b i l i z a t i o n of p o t e n t i a l f o r growth a l s o takes the form of a n x i e t y i n t h e r a p e u t i c r e l a t i o n s h i p s . Because a n x i e t y promotes growth i n these i n s t a n c e s , i t i s termed • p o s i t i v e a n x i e t y . Whether ahe a n x i e t y stems from pathology i n the i n t r a p e r s o n a l o r g a n i -z a t i o n o f a f f e c t , or from the m o b i l i z a t i o n iof a f f e c t f o r growth, i n e i t h e r i n s t a n c e i t antecedes the development of c a p a c i t y to u t i l i z e f e e l i n g i n i n t e r p e r s o n a l r e l a t i o n -s h i p s . . . . The t h e r a p i s t d e a l s w i t h ^Whitaker and Malone; "Roots of Psychotherapy, 1953., p. 123. 101 a n x i e t y both i n the d i s o r g a n i z a t i o n and i n the r e o r g a n i z a t i o n of the p e r s o n a l i t y w i t h i n h i s i n t e r p e r s o n a l r e l a t i o n s h i p to the p a t i e n t . . . • Where the a n x i e t y c e n t e r s around i n c r e a s i n g i n t e g r a t i o n ( p o s i t i v e ) tenseness and expectancy predominate over panic and apprehensiveness.^ Whitaker and -Malone make an I n t e r e s t i n g o b s e r v a t i o n that seems a p p l i c a b l e to the adolescent r e s i s t i n g casework help*. Although communication i s anteceded by anxiety, the experience o f communicating i t s e l f i s s t a r t l i n g l y f r e e o f a n xiety, and accompanied o r d i n a r i l y by other more g r a t i f y i n g a f f e c t i v e of f e e l i n g tones. There comes a sudden i n c r e a s e i n a n x i e t y whenever the p a t i e n t and t h e r a p i s t f a i l to communicate. I f the f a i l u -ure to communicate Is profound enough, the r e s u l t i n g a n x i e t y may assume almost c a t a -s t r o p h i c p r o p o r t i o n s or i n t e n s i t i e s . . . . The above r e f e r s e s s e n t i a l l y to nonverbal a f f e c t i v e communications. Anxiety a l s o i n t e r f e r e s with v e r b a l i d e a t i o n a l communi-c a t i o n . . ."g In the m a j o r i t y of the a d o l e s c e n t s s t u d i e d , t h i s l a c k of communication was an obvious f a c t o r . , The main p o i n t to be made here, however, i s the f a c t t h a t a n x i e t y , whether p o s i t i v e or n e g a t i v e , must be present i n b o t h the worker and c l i e n t to achieve movement towards treatment g o a l s . The worker must develop enough s e l f awareness to determine whether her a n x i e t y i s negative or p o s i t i v e . I f n e g a t i v e , she must c u l l her own experiences to a s c e r t a i n i n what way the adolescent's problem arouses t h i s c o n f l i c t i n h e r s e l f . This need f o r s e l f awareness on.the p a r t of the worker i s not new. I t does seem to the w r i t e r , however, that the • LWhitaker and-Malone; Roots of Psychotherapy, 1953, p.!22» 2 I b i d , p. 128. 102 naturalness of anxiety on the -worker's part, p a r t i c u l a r l y i n work with " r e s i s t i n g adolescents", i s s t i l l not widely accepted or recognized. U n t i l this fact i s faced, the anxiety and the source of negative anxiety i s apt to be repressed rather than worked through. Intake and Overcoming Resistances  1 I f i s only common sense that i f adolescents, as a group, are highly resi s t a n t to treatment, we should being our f i r s t contact with them by being a l e r t to any manifestations of resistance and by paying p a r t i c u l a r attention to the young-ster 's readiness to receive help and enter into a treatment r e l a t i o n s h i p . " I f the intake interview serves to increase the patient's readiness to use help, i t w i l l not aim attreatment of the patient's problems, but rather at enabling the patient to move r e a l i s t i c a l l y into treatment." 1 This i s e s p e c i a l l y true of the adolescent group of patients who are brought to the c l i n i by adults. What good i s a f u l l diagnostic assess- . ment of the youngster's problem i f he i s never able t o use treatment? The intake interviews with teen-age c l i e n t s must aim towards assessing the adolescent's readiness to enter the c l i n i c program. These interviews should have as their prime focus, the preparation of the c l i e n t , on r e a l i s t i c grounds, to u t i l i z e the team services for his benefit. The caseworker carries prime r e s p o n s i b i l i t y i n t h i s process, for she i s the f i r s t person of the psychiatric team ^Anderson, D.M. & Kiesl e r , P.(M.D.): "Helping Toward Help: The Intake Interview", Social Casework, February, 1954, p. 72. 103 '"to c o n t a c t the c l i e n t . She must assess, not o n l y the c l i e n t ' s a b i l i t y to use h e l p , but i f t h i s a b i l i t y Is weak, she must e v a l u a t e the p o s s i b i l i t y o f p r e p a r i n g the c l i e n t for.this h e l p . I f r e s i s t a n c e i s present i n i t i a l l y , t h i s must be diagnosed i f i f i s to be worked w i t h . The causes u n d e r l y i n g the r e s i s t a n c e must a l s o be sought. The f i n d i n g s o f t h i s study about the reasons u n d e r l y i n g r e s i s t a n c e i n adolescents may be h e l p f u l i n t h i s r e g a r d , and c e r t a i n l y many more fa c t o r s , w i l l enter i n . The a d o l e s c e n t ' s f e e l i n g s about h i s r e f e r r a l to the c l i n i c ; the source of h i s r e f e r r a l ; the stimulus l e a d i n g him to take t h i s step; h i s p l a c e i n the f a m i l y ; the i n t e r - p e r s o n a l r e l a t i o n s h i p s i n the f a m i l y — a l l are Important i n such an e v a l u a t i o n . Furthermore, the a d v i s a b i l i t y of d i v i d i n g the case, w i t h one worker seeing the adolescent, another worker h i s p a r e n t s , must be determined e a r l y i n the c o n t a c t . There are many f a c t o r s to be weighed i n making such a d e c i s i o n . Perhaps; the prime determining f a c t o r w i l l be the degree o f p o s i t i v e or n e g a t i v e r e l a t i o n s h i p between parent and c h i l d . The reasons f o r the a d o l e s c e n t ' s r e s i s t a n c e i s important, here too, f o r i f emancipation i s one of the p e r t i n e n t f a c t o r s i n the adole scent's r e s i s t a n c e , e a r l y d i v i s i o n may f a c i l i t a t e h i s use o f c l i n i c h e l p . The parents cannot be ignored, e i t h e r . I f they are r e f e r r i n g t h e i r adolescent c h i l d , t h e i r m o t i v a t i o n f o r seeking c l i n i c help must be c l e a r l y understood. For i n s t a n c e , i f parents r e f e r to t h e i r c h i l d , as d i d Mrs. F u r n i e , as " i n s o l e n t , d i s o b e d i e n t and d e f i a n t " , we must assess the parent's a t t i t u d e towards the c h i l d ' s emancipation. I f t h i s growth away from the f a m i l y i s f r i g h t e n i n g to the p a r e n t s , 104 d i v i d i n g the case on grounds rel a t e d to the adolescent's needs only, may alienate the parents from the s t a r t . They may construe such a move to mean that the c l i n i c worker i s coming between them and the i r c h i l d . This would not be a counter-indication of the need for d i v i s i o n of the case; but f u l l attention would have to be paid to the parent's feelings about i t and worked through very c a r e f u l l y with them. The main point here i s that i f div.ision of the case is indicated, i t should be done as early as possible. The present set up i n the Vancouver Child Guidance C l i n i c should make thi s r e l a t i v e l y simple. The intake conference should not be used as a pre-diagnostic conference, i n which material r e l a t e d to the main problem is aired. I t should concentrate on giving the psyc h i a t r i c team a picture of the adolescent c l i e n t and his family; t h e i r readiness to use help; the impediments to th e i r use of c l i n i c ; and modes of working th i s through. Too often, the caseworker handling the intake takes a l l the r e s p o n s i b i l i t y of getting the c l i e n t through to the diagnostic evaluation. The c l i n i c team i s there to contribute their special s k i l l s towards the solution of such problems and should be used for this purpose. ' Compilation of s o c i a l history material should be a secondary focus i n the intake interviews. The primary focus should be on enabling the c l i e n t to use the service. The aim, of course, i s to help the adolescent and his family make the most of their c l i n i c contact. Often the main problem w i l l play into this process and this must be dealt with; but as an offshoot of this primary enabling process. In dealing with adolescents, the utmost f l e x i b i l i t y i s needed. The 105 need for this can be discussed with the other team members at either the intake or planning conference. The l a t t e r should revolve around the p a r t i c u l a r adolescent's attitude to treat-ment. The caseworker's handling of Dorothy, i n which she helped the g i r l to f e e l that the worker was apart from her mother, i s a case i n point. The f i n a l solution made by Dorothy, was to regard the worker as herown idea, the c l i n i c as her mother's. This i s c e r t a i n l y not a conventional attitude proposed by the c l i n i c team; but It was the only thing that enabled Dorothy to make use of the c l i n i c . Group Approach at Intake ; Peck and Bellsmith^ advocate the use of group process for adolescents who are unable to use in d i v i d u a l casework i n i t i a l l y . They contend that i n no case was t h i s approach detrimental to l a t e r casework on an Individual basis. The importance of the peer group at t h i s stage of adolescent development cannot be overlooked. But do we use this strength enough? There i s a difference between the adolescent who comes to a strange agency (usually on the insistance of some adult i n his environment) tosee an adults'; and the adolescent who comes to the agency to be seen in a group of his peers by one a d u l t . The very fact that he and his age mates outnumber the adult i s important. Also, he i s much more l i k e l y to l i s t e n to his peers and accept their view point, than he i s to acquiesce to an adult person. Since adolescence i s an age of a weak ego that must defend i t s e l f against a f e e l i n g of inadequacy by denying any problems, the very fact that other Ipeck & Bellsmith, Treatment of the Delinquent Adoles-cent, 1954. 106 youngsters are also having d i f f i c u l t i e s serves to bolster his waning s e l f confidence. This approach would seem valuable to the adolescent who already has a f a i r l y good r e l a t i o n -ship with his peers. The youngster whose d i f f i c u l t i e s have been a n t i - s o c i a l behaviour in the company of gangs, would a seeme to be/suitable candidate for such an approach. Also, the youngster who i s unable to tolerate a close personal re l a t i o n s h i p with a caseworker, might benefit from this more impersonal group setting. While we are looking at th i s group approach, l e t us do so from a generic s o c i a l work view point. " F i r s t of a l l , i t i s important to recognize the fact that a l l s o c i a l workers deal with individuals and with groups. Case workers work for the most part with individuals, group workers with primary groups', and intergroup workers with representative groups. Each s o c i a l worker, whether he be a case worker, group worker, or intergroup worker, uses generic s k i l l s and those peculiar to his s p e c i a l i z a t i o n i n f u l f i l l i n g his t o t a l r e s p o n s i b i l i t i e s ; i n f a c t , i t i s the degree to which he uses the sp e c i a l i z e d s k i l l s that determines the worker's c l a s s i f i c a t i o n i n s o c i a l work p r a c t i c e . 1 , 1 It seems to the writer that, i n practice, a gap has arisen between group work and case work that need not e x i s t . The group worker usually functions i n an agency of a l e i s u r e time type. He i s concerned, i n his practice, with the healthier aspects of the personality of the group members. The case-worker, more often than not, i s working with people who are •^Wilson, Gertrude; Ryland, Gladys: Social Group Work  Practice, 1949, p. 23. 107 asking f o r "treatment" of one s o r t or another. These people may be more d i s t u r b e d than the i n d i v i d u a l s found i n a l e i s u r e time agency—but not n e c e s s a r i l y . The d i f f e r e n c e l i e s i n the focus of tte worker according to the f u n c t i o n of the agency i n which he i s employed. The gap a r i s e s from the f a c t that caseworkers regard themselves as competent only to d e a l w i t h people on an i n d i v i d u a l b a s i s ; while group workers regard themselves as competent to de a l only w i t h persons i n groups. There i s a group of prospective c l i e n t s In between, which need more than the f u n c t i o n s of these two kinds of agencies. Perhaps they are d i s t u r b e d youngsters s o r e l y i n need of group experience i n a d d i t i o n to I n d i v i d u a l casework help; or groups of parents and c h i l d r e n who could b e n e f i t from "treatment" w i t h i n a group s e t t i n g . These persons f a l l i n t o the a r t i f i c i a l gap between s o c i a l casework agencies and s o c i a l group work agencies. Remembering that a l l s o c i a l workers possess funda-mental generic s k i l l s ; t h i s lapse of s e r v i c e does not seem necessary. We do recognize the need f o r s p e c i a l i z e d s k i l l s i n v/orking w i t h people i n groups or w i t h people as i n d i v i d u a l s . Taking the b a s i c t r a i n i n g and s k i l l of p r o f e s s i o n a l s o c i a l workers to begin w i t h , there should be l i f t i e d i f f i c u l t y i n adding to t h i s basic t r a i n i n g . The s p e c i a l s k i l l s and i n f o r -mation needed to work w i t h i n d i v i d u a l s i n groups can be learned by the caseworker; j u s t as the s p e c i a l s k i l l s and knowledge p e r t i n e n t to work wi t h i n d i v i d u a l s as such can be l e a r n e d by the group worker; each p r a c t i c i n g these s k i l l s i n the performance o<ff h i s d u t i e s as determined by the f u n c t i o n o f h i s agency. 108 Thus, i n setting up such a group approach within a casework treatment .agency, the main focus must be on preparing the caseworkers for the i r specialized functions as caseworkers de'aling with groups of adolescents. Grunwald and Greving, i n their paper, Casework i n Small Group Settings, presented at the 1953 National Conference of Social Work, U.S.A., define group "counseling" as "an application of casework methods within a group setting" with reference to a group of c l i e n t s who have come to the agency for help with s p e c i f i c problems. The caseworker needs a good background of knowledge about group dynamics. Ideally, consultation provided by a group therapist should be aimed f o r . P r a c t i -c a l l y , where would one f i n d such a "group therapist"? The consultation of a p s y c h i a t r i s t and a group worker could be es t a b l i s h e d f a i r l y r e a d i l y , however, end would fu r n i s h a good source of Information for the casewoder. The composition of such a group would have to be studied c a r e f u l l y to achieve a balance. Some kind of preliminary diagnosis of the youngsters, through individual contact, to determine their p o t e n t i a l use of such a group would be e s s e n t i a l . The reasons for t h e i r resistance; t h e i r r e l a t i o n s h i p to parents and adults generally; t h e i r a b i l i t y to get along with peers; their psychotic or neurotic tendencies: a l l would be pertinent areas to explore. At the same time that we wish some balancing of strengths within the group; we also want a basis of i d e n t i f i c a t i o n that goes further than the mere fact that the adolescents are of the same age and the leader of the group is an adults The s i m i l a r i t y of problems consciously faced w i l l be a further i d e n t i f y i n g factor. Here, 109 too, a balance i s necessary. I f some adolescents have been able to cope adequately w i t h problems the other members of the group face; then they are i n a p o s i t i o n to exchange strengths through the group medium. And of course, i t i s of v i t a l importance, that at l e a s t some of the members are capable of a p o s i t i v e r e l a t i o n s h i p w i t h an adult i f the group i s not to d i s i n t e g r a t e i n t o a r e b e l l i o u s mob held together by t h e i r d i s t r u s t of a l l " a u t h o r i t a t i v e " a d u l t s . Peck and B e l l s m i t h have used t h i s approach w i t h parents, too, w i t h p o s i t i v e r e s u l t s . However, t h i s whole area of p a r e n t a l a t t i t u d e s towards the treatment of t h e i r adolescent c h i l d r e n and t h e i r own involvement i n treatment embodies a separate study i n and of I t s e l f . The support rendered to the i n d i v i d u a l by h i s age group cannot be overestimated at t h i s adolescent p e r i o d of development when defenses are threatened by the very f a c t that" outside p r o f e s s i o n a l help i s sought i n the s o l u t i o n of h i s d i f f i c u l t i e s . In a s e t t i n g such as the Vancouver C h i l d Guidance C l i n i c , where no group approach has yet been attempted; s p e c i a l problems i n s e t t i n g up a program of t h i s s o r t a r i s e . However, none of these problems are unsurmountable. The w r i t e r does not b e l i e v e i t i s necessary to engage f u r t h e r s t a f f from the group work f i e l d . A group work consultant who would be able to spend considerable time i n helping to set up such a program i n i t i a l l y , and who could be contacted f r e q u e n t l y f o r advice as the group progressed, would perhaps be s u f f i c i e n t . One or two experimental groups could be set up to begin w i t h . Space should not be too much of a problem since the groups should be l i m i t e d to 6 or 8 youngsters•and t h i s 110 s m a l l group could.be seen i n any of the l a r g e r i n t e r v i e w i n g o f f i c e s . The experiences of other p s y c h i a t r i c agencies i n u s i n g such an approach, c o u l d be u t i l i z e d i n p l a n n i n g such an experimental program. C o n f i d e n t i a l i t y i s another t h i n g to c o n s i d e r c a r e f u l l y i n such a program. To caseworkers who d e a l w i t h i n d i v i d u a l s , i t i s a simple matter to assure t h e i r c l i e n t t h a t what he d i s c u s s e s i n the i n t e r v i e w w i l l be t r e a t e d w i t h utmost c o n f i d e n t i a l i t y . Such assurance i s not r e a l i s t i c when the c l i e n t d i s c u s s e s h i s p e r s o n a l problems i n a--group s e t t i n g . The s i t u a t i o n needs t o be c l a r i f i e d f r a n k l y w i t h the i n d i v i -d u a l members o f the group p r i o r to t h e i r i n i t i a t i o n i n t o t h i s type of group d i s c u s s i o n . The r e a l i t i e s o f d i s c u s s i n g i n t i m a t e d e t a i l s and the p o s s i b l e consequences must be l a i d out bef o r e the i n d i v i d u a l so t h a t he may choose to d i s c u s s o n l y those t h i n g s he regards as s a f e . Again, the whole q u e s t i o n can be d i s c u s s e d by the group and they w i l l probably come up w i t h t h e i r own s o l u t i o n , h o p e f u l l y f a v o u r a b l e to the c o n s t i t u e n t s o f the group. However, the arrangements need to be c l a r i f i e d both i n d i v i d u a l l y and as a group. The value of t h i s group approach i s d i f f i c u l t to assess without some expe r i m e n t a t i o n . This w r i t e r f e e l s that such an approach would be v a l u a b l e d i a g n o s t i c a l l y as w e l l as i n h a n d l i n g r e s i s t a n c e . I t would g i v e a unique o p p o r t u n i t y to see the i n d i v i d u a l adolescent i n h i s peer s e t t i n g . Group Approach i n Treatment Hot only may a group approach be used d u r i n g the int a k e process; but a l s o on a c o n t i n u i n g b a s i s , b o t h w i t h or w I l l without Individual casework interviews. Peck and Bellsmith found i n their work with r e s i s t i n g adolescents; that whereas i t had been d i f f i c u l t to bring the resistance of these c l i e n t s into the open through casework treatment, this was accomplished quickly with some of the c h a r a c t e r i s t i c aspects of resistance through the group sessions. Not only i s resistance l i k e l y to be more externalized i n a group setting; but both the worker and the group can aid the p a r t i c u l a r adolescent i n his struggle with his problem. In the Child Guidance C l i n i c , groups could be used experimentally for treatment of these adolescents by contin-uing the o r i g i n a l intake groups, with some modifications, through t h i s period. Should such an experimental program be set up, the question of interviewing parents i n similar groups should also be explored. Diagnostic Understanding of Resistance "Resistance, of course, may serve as the worker's f i r s t therapeutic foothold. But before i t can be u t i l i z e d as a means of involving the patient, i t must f i r s t be cor r e c t l y diagnosed and understood by the therapist and made apparent to2the patient through the medium of the r e l a t i o n s h i p . . . • We noted i n ind i v i d u a l treatment e f f o r t s , however, that a strong resurgence of resistance often appeared just at the point when posit i v e feelings toward the therapist seemed to be developing and r e a l movement appeared to be taking p l a c e . " 2 1Peck and Bellsmith; Treatment of the Delinquent  Adolescent, 1954, p. 68. 2 l b i d , p. 74-75. 112 The diagnosis of resistance and i t s underlying: causes, must be viewed as something quite apart, in focus, from the diagnosis of the major, or presenting problem with which the adolescent is brought to the c l i n i c . In the case of youngsters i n whom emancipation plays a v i t a l role i n their resistance to treatment, the entire family c o n s t e l l a t i o n and the way i n which the family i s contributing to the youngster's s t r i v i n g s towards independence, must be assessed. Should the parents be attempting to hold t h e i r c h i l d to them i n a dependent r o l e , they must be given a chance through c l i n i c help, to work out their c o n f l i c t s d i r e c t l y through treatment, rather than i n d i r -e c t l y through their children. The whole pattern of r e l a t i o n -ship to authority; the present source of r e f e r r a l ; and whether or not this i s construed as another authoritatiye move by the adolescent, must be c a r e f u l l y studied. Some adolescents . . . "think of treatment as a new form of adult control and punishment and react to the experience strongly and negatively." Interpretation and Resistance One more reason for the necessity of making a careful study of the reasons underlying the resistance manifested by the adolescent i s the fact that his "resistance" may merely comprise his defenses against uncovering material he i s try i n g hard to repress. At this time of l i f e , the adolescent, with his weak ego faces many c o n f l i c t s at a conscious or preconscious l e . v e l . Sometimes the very resistance manifested by the youngster i n i t i a l l y , i s an i n d i c a t i o n of how close to the surface these c o n f l i c t s are. "Understanding the i n i t i a l ••-Peck and B e l l s m i t h , Treatment of the Delinquent  Adolescent, 1954, p. 33. 113 resistance of delinquents is important diagnostically. As with any c l ient , i t may be an indication of how deep-rooted or how near the surface the confl ictual matrix i s . With delinquent adolescents, however, acute i n i t i a l resistance is not necessarily an inseparable part of the adolescent's central problem. Only i f resistance is seen in relation to the total personality and as a modus vivendi in the adoles-cent's dilemma, can i t be correctly assessed. 1 , 1 Should this i n i t i a l resistance be an indication 6f an attempt to suppress confl ictual matter; i t iands to reason that the caseworker must be aware of this to avoid prec ip i -tating further resistance by re-opening these wounds. Such a tentative diagnosis gives the worker direction to piBcede along real i ty issues and to help the adolescent build up his defenses. The adolescents in this study, whose oedipal attachments to parents Interfered with their ab i l i ty to accept treatment, seemed to see this c l in i c help as a threat to their arduously bui l t up defenses. They are, perhaps, the ones most obviously in need of help in building defenses and in protecting themselves from external situations that excessively stimulate their inner drives. The relationship of the adolescent cl ient to his worker must be carefully analysed for indications of transference and counter-trans-ference. Dr. Gaston E . Blom 1, in his treatment of a delinquent adolescent boy with an unresolved oedipal fixation comments Ipeck"and'Bellsmith, Treatment of the Delinquent  Adolescent, 1954., p. .35. ^Associate Director, Child Psychiatry Unit, Massa-chusetts General Hospital, Boston, Massachusetts. 114 that: "The ambivalence and resistance to treatment- seemed centered on his d i f f i c u l t i e s with the transference r e l a t i o n -ship. He feared being dependent but he primarily feared his homosexual fee l i n g s and fantasies. He sexualized the r e l a t i o n s h i p to the therapist as he had other situations and i t was not possible to obtain and maintain a good working transference r e l a t i o n s h i p . " 1 Sylvan Keiser points out as well, i n his treatment of a f i f t e e n year old adolescent g i r l with a manifest oedipus complex "that this patient could only have a sexualized r e l a t i o n s h i p . Either she became sexually involved or else she could have no contact with either male or female." 2 This type of sexualized r e l a t i o n s h i p Is perhaps most obvious i n Edith, who seemed frightened after her passionate outbursts towards the worker. It i s ce r t a i n l y something to watch for i n any adolescent. The degree of anxiety the adolescent can tolerate in the face of such a sexualized. relationship, without withdrawing from treatment i s of the essence i n handling such resistances. Also, the degree of close relationship that the adolescent can manage without severe anxiety leading to f l i g h t is important so that the caseworker can gear the therapeutic rel a t i o n s h i p to that degree of closeness. The Community and the Adolescent The basic problems i n dealing with adolescents are i n the shortage of trained personnel and the lack of adequate ^Blom, Gaston E. (M.D.); "Ambivalence and Resistance to Treatment i n a Delinquent Adolescent Boy", American Journal of  Orthopsychiatry, July, 1952, p. 606. SKeiser, Sylvan (M.D.).; "A Manifest Oedipus Complex In An Adolescent G i r l " , The gaychoanalytic Study of the Child,VIII, 1953, p. 103. 115 community resources. There must be f a c i l i t i e s within the community for meeting the adolescent's needs. "No treatment process is r e a l l y useful unless i t takes into consideration the pressing r e a l i t y conditions that form the context of the c l i e n t ' s l i f e . ' ! l We must know the pressures from the court, school, family and neighbours to which the adolescent i s subjected. "Actually i t i s often advisable for the worker to assume the role of act i v e l y protecting the adolescent against r e a l i t y pressures." 2 Of necessity, the Child Guidance C l i n i c treats adolescents, who are for the most part, l i v i n g in their own homes. Therapeutically, the c l i n i c team would prefer to work with some of these adolescents while they are removed, from t h e i r poor home si t u a t i o n s . However, few f a c i l i t i e s e xist within Vancouver to allow, such a plan. Foster homes for adolescents have always been scarce; and. i n many instances are only second best choice i n the absence of any treatment center for this group of c l i e n t s . It i s extremely d i f f i c u l t , i f not impossible, to overcome the traumatic experiences some of these youngsters have within th e i r own fami l i e s , by seeing them for one hour a week while they spend the remaining 167 hours i n the same si t u a t i o n i n which their problems arose. Ideally, . . . "A decision to engage i n extramural treatment must be based on a careful scrutiny and evaluation of the p o t e n t i a l i t i e s for mutual tolerance betwsen the adolescent and his family." P r a c t i c a l l y , when such mutual tolerance i s non-Peck & Bellsmith; "Treatment of the Delinquent  Adolescent, 1954, p. 21. 20p. C i t . - 3 I b l d , p. 25. 116 existant, we must continue to treat the adolescent in his . own home with this Intolerance serging as a further obstacle to his use of treatment services. Intensive studies 1 are currently being conducted upon this very need for such a treatment center for disturbed youngsters., while they are undergoing casework or psychiatric treatment. The value of a therapeutic environment for these youngsters who are unable, t o use casework treatment while l i v ing in their own homes cannot be overestimated. It is this writer's opinion that with this adolescent group, in which so much of their resistance was direct ly attributable to conflicts within the family situation i t se l f , such a center could do much to counteract many of the resistances met in treatment. Although Peck and Bellsmith have confined their study to delinquent adolescents, many of their findings have implications for adolescents regardless of the problems which bring them to the Child Guidance C l i n i c . They point out that . . . "It is a l l very well to say that an adolescent should be treated extramurally, but unless the agency undertaking this treatment can provide the sk i l l s necessary for working with this particular adolescent, the gesture of 'saving him from an inst i tut ion' w i l l be a pretty empty one. It may be noted "here that when i t is not possible to give a f i r s t appointment unt i l six months or a year after re ferra l , entering the name on,a 'waiting l i s t ' is- sometimes worse than not accepting the referral at a l l in view of the rapid deterioration 1Notably, Robert McDonald, of the Vancouver Child Guidance C l i n i c , M.S.W. Thesis on the need for such a' treatment center for emotionally disturbed children and the means of setting up such a program. 117 that so often takes place after an adolescent has been brought to c o u r t . " 1 This problem of "waiting l i s t s " confronts every agency which i s overworked and understaffed. The Vancouver Child Guidance C l i n i c i s no exception to t h i s . But what else can we do when no other f a c i l i t i e s are available fo r these youngsters? Within this group of t h i r t y adolescents, we f i n d various special probfems to be dealt with. There are dependent children, requiring either foster home placement or treatment center f a c i l i t i e s . In the majority, these youngsters are brought to the c l i n i c because they are unable to respond to foster home placement. It i s questionable, whether i t i s wise to pla-ce adolescents i n foster homes i n the f i r s t p l a c e . 2 But, i f we are to make a choice on therapeutic grounds, we must have the f a c i l i t i e s allowing us to make such a choice. Then, there are the delinquent group who have been through the Juvenile Court, the Juvenile Detention Home or Ind u s t r i a l Schools. If we are to treat such a group of children, we must do so while they are l i v i n g within one of these detention homes or within their own homes. Again, there i s the rejected c h i l d and the deprived c h i l d . At the very least, we cannot ignore t h e i r r e a l i t y s i t u a t i o n s . How i s the s o c i a l worker to play a protective role to such children within the narrow confines of weekly casework contacts. Sometimes, the worker can enable the family of such adolescents to u t i l i z e more f u l l y the available f a c i l i -t i e s within the community. At other times, concerted community 1 Peck & Bellsmith,"Treatment of the Delinquent Adol^ escent, 1954, p. 22. * * ^ 2McLaren, Monty, M.S.W. Thesis, 19.54, on the a d v i s a b i l i t y of foster home placement of adolescent boys and the success of s ame. . 0 118 action must be stimulated to r e c t i f y the defects i n s o c i a l arrangements within the community. Prevention The mere existance of recreational, s o c i a l and vocational f a c i l i t i e s within the community does not guarantee the adolescent's use of them. However, they are often v i t a l to the adolescent, whether he i s aware of t h e i r existance or not. Vocational guidance may be one of the adotescent's most pressing need. There are ...facilities within the Van-couver area to meet th i s need; but how do we enable this adolescent group to benefit from them? As a preventative service, we cannot wail/ u n t i l they come to a s o c i a l agency to d i r e c t them to such f a c i l i t i e s . It i s within the schools themselves that such d i r e c t i o n must come. The value of s o c i a l workers i n the school has been expounded2in previous s t u d i e s . 1 This area of vocational counseling i s but one way i n which the s o c i a l worker may help so c a l l e d "normal" adolescents. This is the setting i n which early d i f f i c u l t i e s may be diagnosed and r e f e r r e d for help. Ultimately, s o c i a l workers must be included i n the school program. U n t i l such time, however, a closer cooperation between the school and the s o c i a l agencies who eventually see the disturbed youngsters from this setting i s essential.. An a r t i f i c i a l gap between the mental hygiene movement of the schools and s o c i a l agencies i s now present. A study on the possible closer integration between these two programs would seem b e n e f i c i a l at t h i s point; for i t i s only 1Thomson, Mary, The Social Worker i n the School, M.S.W. Thesis,1948, U.B.C. Also Prances McCubbin's thesis of 1953, on counselling at the Junior High School l e v e l . . 119 when a l l f a c i l i t i e s are well integrated that the best benefit accrues to the adolescent with whom we are concerned. Another facet of prevention is that comprising an educational program for parents. Lack of knowledge about their children Is not necessarily the primary problem of parents of adolescents who come to the Child Guidance C l i n i c . However, in p r a c t i c a l l y every case, there i s a. gap In parents* knowledge about children's needs and development, e s p e c i a l l y of the adolescent age, which could be r e c t i f i e d p a r t i a l l y through this educational approach. The role of s o c i a l workers i n programs of th i s sort has been written about widely.1 Gunnar;;Dybwad asserts that "Present day knowledge of children's needs and good c h i l d rearing practices should be e a s i l y accessible to a l l parents and available i n such a way that i t becomes incorporated into t h e i r thinking and f e e l i n g . The all-important task of child.rearing can no longer be l e f t to chance.W2. This a r t i c l e r e i t e r a t e s the r e s p o n s i b i l i t y of soc i a l agencies,dealing with families, to regard this edu-cation of parents as a professional function of their agencies in the community. "Group education, . . . is oriented to the healthy factors of the personality with the goal of helping parents gain an understanding of themselves and their children anda an increased capacity to make their own choices on the basis of such understanding. Thus group education i s to be under-stood as a dynamic learning experience which goes far beyond -'•See i n p a r t i c u l a r , Smith, Marjorie Vivian, Contri-butions of the SocialWorker i n Parent Education, M.S.W. Thesis, F a l l , T9T2T"U.B.C. •- — -2Dybwad, Gunnar, J.D., "Leadesship i n Parent Edu-cation", Children, January-February, 1954*, p. 14. 120 i n t e l l e c t u a l absorption of new knowledge through didactic process, since i t a c t i v e l y involves the feelings and attitudes of the group members."1 Although the s o c i a l worker needs further knowledge about the content of such parent education groups and about the process of group dynamics, she i s i n an excellent p o s i t i o n to give profes-sional leadership to such a group. Conclusion It appears that adolescent resistance to treatment Is almost inevitable i n those youngsters who have suffered severe d i f f i c u l t i e s i n relationship to their parents. The writer does not regard t h i s resistance as something that can be overcome completely. However, the fact that these t h i r t y adolescents showed a r e a l t i e up between t h e i r resistance to treatment and the adolescent period,with a l l i t s t r i b u l a t i o n s , does give us a basis for understanding i n d i v i d u a l resistance and gearing our handling to the underlying reasons for i t s manifestation. The del i c a t e balance betwffin parents and children i n even "normal" adolescents makes us pay close attention to this r e l a t i o n s h i p and i t s e f f e c t on the adolescent's use of treatment. Adolescents w i l l continue to come to treatment agencies,, not on their own i n i t i a t i v e , but because parents their or other adults see the need for/treatment. The demon-strated i n a b i l i t y of youngsters i n their teens to recognize their problems and their need for help leads the writer to •^Dybwad, Gunnar, "Leadership i n Parent Education", Children, January-February, 1954, p. 11. 121 believe that even after the adolescent i s In contact with the agency, we cannot leave i t "up to him" e n t i r e l y , whether or not he w i l l continue to patronize the c l i n i c . There i s some comfort i n the fact that some adolescents do receive benefit, "In spite of themselves" from "agressive casework". But we need to know more s p e c i f i c a l l y what adolescents do receive benefit from t h i s going out to them In order th&.t our l i m i t e d resources may be directed e f f i c i e n t l y to those youngster who are capable of be n e f i t t i n g from c l i n i c services. Just because many adolescents have shown a need to be "chased" by the caseworker; and because another, adult contact may mitigate some of the previously poor associations these adolescents have experienced with adults--is no reason for caseworkers, to never r e l i n q u i s h a r e s i s t i n g adolescent. ¥/hat i s needed i s more evidence about the res u l t s of casework contact with these " d i f f i c u l t " c l i e n t s . Our only source of v a l i d information i s the c l i e n t himself, Such a follow-up study i s v i t a l l y necessary, i f only for purposes of economy. Adolescents manifesting resistance are not the only group needing help from Child Guidance C l i n i c personnel. We must know i f the time entailed i n following these youngster s through t h e i r resistance i s j u s t i f i e d i n the o v e r - a l l picture of c l i e n t e l e needs. Experimentation i n the more impersonal group approach may reap rewards i n this problem of handling adolescent resistance. At any rate, expecting resistance from this type of c l i e n t , we should be more a l e r t to some of the possible reasons for i t and thus gear our treatment accordingly. Name: 122 APPENDIX A Proposed Outline for Studying Case Material Status of case: Examination Date: Age: Pre-adoleseent_ Sex: FAmily Parents: Names: Post adolescent Adolescent School: Occupation i f not i n school: Grade: Ages: Both l i v i n g : Mother dead Father dead Married Widowed Separated Divorced Deserted Remarried Adopted Evaluation of mari t a l adjustment: Si b l i n g s : Names: Ages School Grade_ Occupation i f not i n school;" Position of c l i e n t : (1st, 2nd, etc.) Contact with Agency^ Personal Application / Referred by Agency / Referred by private Individual (heard of CGC through) 0- previous contact 1- c l i e n t or ex-client 2- private i n d i v i d u a l 3- other s o c i a l agency 4- CGC p u b l i c i t y 5- other source 12- neighbour or fr i e n d 13- r e l a t i v e or c l i e n t •14- physician 6- hospital c l i n i c or health agency 7- school or Board of Education 8- children's agency neighbourhood house 15- other 9- court, l e g a l or 16 parent protective agency 10- public welfare' 11- church or r e l i g i o u s agency Major stimulus i n application to CGC& ...0. Own. i n i t i a t i v e ...1. Suggestion or advice of others •..2. Social pressure from others ...3. Authoritative r e f e r r a l ...4. Other (specify): ...5. I n s u f f i c i e n t information Presenting Problem: 1. As stated by c l i e n t . 2. As stated by parents or source of r e f e r r a l , Kogan, Hunt, Bartelme, A Follow-Up Study of the Results  of S o c i a l Casework, New York, Family Service Association of America, lyb3. Modifications of shedules, AppendixA 123 Appendix A (continued) C l i n i c a l Diagnosis; (following conference) Participation in Interviews^ (for mother, father & adolescent) Individual's Behaviour During:-Degree of Participation I n i t i a l Expiratory Subsequent with Caseworker Interview Process Process High degree Of participation Moderate degree of participation Ambivalence Moderate degree of resistance High degree of resistance Insufficient evidence Appointments and Interviews^ (for mother, father & adolescent) Considering a l l the interviews held with this individual the category is chosen that best describes the frequency with which each aspect of interviewee behaviour liste d below occurred. Category: 1. Invariably 2. episodically 3. occasionally 4. rarely 5. never 6. not relevant 7. insufficient evidence ...a. be early for interviews ...b. be late for interviews ...c. keep appointments promptly ...d. break appointments ...e. prolong interviews . . . f . cut interviews short ...g. other behaviour (specify)i .Present Status of Case: Closed a. mutual decision of client and worker b. decision of client, only. Open treatment continuing according to plan. 124 APPENDIX B Course of Resistance in-Individual Adolescents according Case to Pattern I n i t i a l Interviews Exploratory Interviews Subsequent Process A. Progressive Resistance Danny Edit h Doris L i l a Thelma Lois Roxie George June Wilma Noreen Susan Sheila Prances Shirley Ambivalent Moderate P a r t i c i -pation Moderate P a r t i c i -pation Moderate P a r t i c i -pation High P a r t i c i p a t i o n High p a r t i c i p a t i o n Moderate p a r t i c i -pation High p a r t i c i p a t i o n High p a r t i c i p a t i o n Moderate resistance Moderate p a r t i c i -pation Moderate p a r t i c i -pation Ambivalent High p a r t i c i p a t i o n Moderate p a r t i c i -pation Ambivalent High Resis-tance Ambivalent-Moderate Par-t i c i p a t i o n Moderate Resistance Hi p a r t i c i -p a t i o n Moderate resistance Moderate resistance High Resis-tance Moderate resistance Moderate resistance Moderate resistance Moder ate resistance Ambivalent Moderate resistance Moderate Resistance EighoRe-sistance Moderate Resistance High Resist-ance High Resistance Ambivalence Withdrawal High Resistance High Resistance High Resistance High resistance High resistance High resistance High resistance High resistance B. Swings i n Resistance Ann § Florence Moderate resistance High r e s i s t - Moderate resistance, ance Moderate resistance Moderate Moderate r e s i s t p a r t i c i p a t i o n tance 125 Case Appendix B (Continued) I n i t i a l Interviews - Exploratory Interviews Subsequent Process B. ' A Jo-Ann G l o r i a Grace Sandra Moderate resistance High resistance Moderate p a r t i c i -pation Moderate resistance Moderate Moderate p a r t i c i p a t i o n resistance Moderate High resistance resistance High p a r t i c i - High resistance pat ion Moderate High resistance p a r t i c i p a t i o n C. Consistent Resistance Penny High resistance High resistance High resistance Graham Moderate resistance Moderate Moderate resistance resistance Mary High resistance High resistance High resistance Betsy Moderate resistance Moderate Withdrawal . resistance Joan Ambivalent Ambivalent Ambivalent D. Decreasing Resistance Diane A John A Dorothy A Betty Moderate resistance High resistance High resistance Moderate p a r t i c i -pation Moderate resistance High resistance Ambivalent Moderate resistance Moderate p a r t i c i p a t i o n Ambivalent High p a r t i c i p a t i o n Moderate p a r t i c i -pation. # Those youngster referred to other agencies A Those youngsters continuing treatment at CGC. 126 APPENDIX C Presenting Problem and C l i n i c a l Diagnosis . of Individual Adolescents by Cause of Resistance Case Presenting Problem C l i n i c a l Diagnosis A. Emancipation Prances, 18 Cannot stand on her own feet Shirley,II D i f f i c u l t to d i s c i p l i n e Edith, 15 Stealing Sheila, 16 Insolent, disobedient. Sandra, 15 Resents authority, runs away. Penny, 13 Rebellious Dorothy, 14 Fear of growing up Neurotic disturbance; use of intelllectualization and v e r b a l i z a t i o n as defense. Aware of affec t ; unable to handle same. Immature and ego-eentred. High general i n t e l l i g e n c e Confused as to how to conform; closer r e l a t i o n -ship to father than mother. Regards mother as punitive & r e s t r i c t i n g & perfection-i s t i c . High i n t e l l i g e n c e . Threatened by l i v i n g m th father, slone. Regards him as sexual object. P o s s i b i l i t y of f i i g i d i t y or promiscuity. Signs of inversion & homosexual attachments. v Hostile to\vards everyone. Negative male concept. "Do nothing" negativism to punish mother. Slow normal Intel l i g e n c e . Fantasy tendencies; with-drawing from people. Lacks r e a l i s t i c male concept. Feels rejected. Bright  normal i n t e l l i g e n c e . C o n f l i c t between impulses and controls. Hostile towards parents and their control. Peels father is unfeeling and punitive. Sadistic need to hurt people; h o s t i l e to men. High a s p i r a t i o n s — i n t e l -l e c t u a l achievement her only s a t i s f a c t i o n . Superior  i n t e l l i g e n c e . 127 Appendix C (Continued) A. Case presenting Problem C l i n i c a l Diagnosis Betty, i s Cannot be trusted. B. Oedipal Attachments Thelma,17 Mother banished g i r l from home. susan, 13 Disobedient and defiant to mother. Florence, 16 Wants to leave school. Dependent on mother. Fear of f a i l u r e . So s k i l l i n inter-personal r e l a t i o n s h i p s . Bright  normal i n t e l l i g e n c e . Ann, 12 Jealous of father's Withdrawal tendencies. second wife. Unacceptable s o c i a l standards. No Reeling of belonging; feels unable to please step-mother. Only sa t i s f a c t o r y r e l a t i o n s h i p was with adopted mother--rel a t i o n s h i p with father s u p e r f i c i a l — r e g a r d s him as a resource. High  superior i n t e l l i g e n c e . Roxie, 12 Threat to father's Overly concerned and g u i l t y second marriage (step r e heterosexual r e l a t i o n s , mother says) Fear of Lacks adequate and affee-g i r l ^ getting into sexual tionate parental figures, d i f f i c u l t i e s . Desire to escape step-mo. Low average i n t e l l i g e n c e Acutely disturbed. Problems of sexual adjustment. Fantasy regarding foster home. Impersonal treatment setting recommended. No a b i l i t y to form close r e l a t i o n s h i p s . Some ins ight into anxiety and depressions. Onset of paranoid schizo-phrenia, unable to accept mother's r e a l r e j e c t i o n . Bright normal i n t e l l i g e n c e . Lack of s e l f oonfidence. Unsatisfactory home and school r e l a t i o n s h i p s . Middle of general i n t e l -ligence. 128 appendix C. (continued) Case . Presenting Problem C l i n i c a l Diagnosis Lois, 18 Mother possessive ( g i r l ) Some schizoid tendencies. Inadequate personality from environment and neurotic mother, Jo-Ann, 12 Acting out father's fantasies of whoredom. D i t t o . Aim towards achievement of successful womanhood in spite of parents. John, 13 Betsy, 12 Delinquent. Eneuresis, i n a b i l i t y to mix with others. Emotionally disturbed. Peeling insecure, inade-quate & confused. Fear of being a male c h i l d . A b i l i t y to r e l a t e . Average general i n t e l l i g e n c e with superior p o t e n t i a l i t i e s . No diagnostic examination. C. Emancipation & Oedipal Attachments, G-raham, 13 Noreen, 16 L i l a , 13 Mary, 13 Poor relationship with women. Disobedient & resent-f u l since father's death. Thefts & l y i n g . aggravates father--according to mother. L i t t l e affection or s a t i s f a c t i o n from parents. Low i n slow general  i n t e l l i g e n c e . Lack of confidence. Wish to escape family. Lacks aff e c t i o n , support & adequate male conception a r e a l i s t i c basis. Anxiety in sexual area. Bright normal in t e l l i g e n c e with r e a l i s t i c ambitions. Insecure & anxious. Unable to please mother, whom she regards as r e s t r i c t i v e & authoritative. Controls feelings r i g i d l y . No adequate male concept. High general i n t e l l i g e n c e . Early schizoid tendencies. Borderline i n t e l l i g e n c e with much f e e l i n g about her l i m i t a t i o n s . Pushed beyond a b i l i t y . Immature. Peels unaccepted by family. 129 Case C. Doris, 10 Danny, 12 Diane, 16. Appendix C. (continued) Presenting Problem C l i n i c a l Diagnosis Physical symptoms -e f f o r t s to get father's attention. Aggressive behaviour-slow i n school. Uncooperative & stub-born; i n a b i l i t y to complete things. No a f f e c t i o n a l r e l a t i o n -ships. No recognition of a f f e c t i o n a l needs. Not seeking affection; but control, security & consistency. Sex disturbances. Hostile to parents. Superior Intelligence. Organic abnormalities. High i n d u l l normal  i n t e l l i g e n c e . Lack of inner strength. Expres-sion of hostilSy prevented bg[ g u i l t f e e l i n g s . Able to r e l a t e to own sex, only. No adequate male concept. Unable to accept aggressive fe&Ings. Doesn't trust own judgement or a b i l i t y . High i n average i n t e l l i g e n c D. I n a b i l i t y to Relate June, 15|r stealing, eneuresis Grace, 13 Stealing, Wilma, 13 Stealing, l y i n g , defiant, destructive. Heterosexual relations confused. GuSlt and anxiety re sex. Lacks normal father f i g u r e . Peels inadequate & un-loved. Mid-average i n -telligence . Fearful of r e j e c t i o n . Slow normal in t e l l i g e n c e . S u p e r f i c i a l i n t e r -personal rela t i o n s h i p s . Hostile towards women. Anxious & immature. High  average i n t e l l i g e n c e . E. I n a b i l i t y to Relate & Emancipation George, 13 Backward in school, jealous of s i b l i n g s . Denies need for affection-received none. I n a b i l i t y to r e l a t e . Hostile & r e s e n t f u l of parents. Mid-average int e l l i g e n c e . Case 130 Sppendix C. (continued) Presenting Problem C l i n i c a l Diagnosis Glo r i a , 14 Promiscuous, alcoholic I n a b i l i t y to form anything but s u p e r f i c i a l r e l a t i o n -ships. Successful group  p a r t i c i p a t i o n . Good sense of worth; s o c i a l standards good. Poor family r e l a t i o n -ships; nervaas symptoms. Low average i n t e l l i g e n c e . Prognosis poor. Mother & daughter seeing same worker because mother cannot use help. Joan, 17 Anxiety attacks Schizoid tendencies. Seen by p s y c h i a t r i s t - but no other team member s. Introspection to be avdtded. // 131 BIBLIOGRAPHY Books Bios, Peter, The Adolescent Personality, Appleton Century, Crofts, Inc., New York, 1941. Cole, Luella, (Ph.D.), Psychology of Adolescence, Rhlnehart & Co., Inc., 1948 (3rd e d i t i o n ) . English, 0. Spurgeon, M.D.; & Pearson, Gerald, H.J., M.D.: Emotional Problems of Living, W.W. Norton & Co. Ltd., New York, 1945. . Farnham, Marynia F., (:Mi-D> '),;,The. Adolescent, Harper & Brothers,., New York,. 1951. ('""c , c.' ' > - ). Garrison, Karl C> Psychology of. Adolescence, Prentiee H a l l , Inc., 1951!^ (4th,edition). Hamilton, Gordon, Theory and Practice of Social Casework, Columbia University Press, New York, 1951 (2d ed. revised)• Josselyn, Irene M. (M.D.), The Adolescent and His World, Family Service Association of America, New York. Kogan, Leonard S.; Hunt, J.; McVicker, Barteleme; P h y l l i s F.; A Follow-Up Study of the Results of Social Casework, Family Service Association of America]. New York, 1953. Peck, Harris B.; Bellsmith, V i r g i n i a ; Treatment of the Delinquent Adolescent, Family Service Association of America, New York, 1954. Strode, Josephine & Pauline R., Social S k i l l s in Casework, Harper & Brothers, New York, 1942. Whitaker, Carl A . , M.D.; Malone, Thomas P., Ph.D.; The Roots  of Psychotherapy, The Blakiston Company, New York, 1953. Wilson, Gertrude; Ryland, ©ladys; Social Group Work Practice, Hughton M i f f l i n Company, Cambridge, Massachusetts, 1949. Pamphlets and A r t i c l e s Alien, F.H. "Creation and Handling of Resistance i n C l i n i c a l Practice!,"American Journal of Orthopsychiatry, 2:268, July, 1932. Anderson, Delwin M.j Kei s l e r , Frank; ^Helping Toward Help! The Intake Interview", Social Casework, XXXV, 2, February, 1954, F.S.A.A.?' New York. 132 Bibliography Benedek, Therese; "Personality Development", i n Dynamic Psychiatry, (Ed. Alexander, Franz & Ross, Helen), University of Chicago Press, Chicago, 1952. Biestek, F e l i x P.; "An Analysis of the Casework Relationship Social Casework, XXXV, 2, February, 1954, F.S.A.A., New York. "The Non-Judgmental Attitude", S o c i a l Casework, June, 1953, F.S.A.A., New York. Bloch, Donald A.,'M.D.; "SomevConcepts i n the Treatment of Delinquency", Children, March-April, 1954, U.S. Department of Health, Education & Welfare,' Children' Bureau, Washington, D.C. Blom, Gaston E., M.D.; "Ambivalence and Resistance to Treatment i n a. Delinquent Adolescent Boy", Workshop 1951, Reprinted from American Journal of Orthopsy-chiatry, July, 1952. Bowers, Swithun; "The Nature and D e f i n i t i o n of Social Case-work, Printed i n three parts i n the Journal of  So c i a l Casework, October, November, December, 1949, F . S . A . A . , New York. Dybwad, Gunnar, J.D., "Leadership i n Parent Education", Children, January-February, 1954, U.S. Department' of Health, Education &. Welfare, Children's Bureau, Washington, D.C. E d i t o r i a l Notes, "Relationship Factors", Social Casework, July, 1953, F.S.A.A., New York. Ellsworth, Dorothy; "Precocious Adolescence i n Wartime", i n the pamphlet of the same name, Reprinted from The  Family, March, 1944, F.S.A.A., New York. Goldsmith, J.K.,'"Treatment of an Adolescent with a Super-ego Defect", Social Casework, A p r i l , 1950, F.S.A.A., New York. Hanford, Jeanette; "The Place of the Family Agency i n Marital Counseling", Social Casework, June, 1953, F . S . A . A . , New York. Keiser, Sylvan, M.D.; "A Manifest Oedipus Complex i n an Adolescent G i r l " , The Psychoanalytic Study of the  Child, VIII, International Universities Press, New York, 1953. Lane, Lionel; "Agressive Approach i n Preventive Casework with Children's Problems,"Journal of Social Casework February, 1952, F.S.A . A . , New York. 1 3 5 Bibliography Lewis, Margaret L.;'"The I n i t i a l Contact with'Wives'of Alcoholics", Social Casework, January, 1954, P.S.A.A., New York. M i t c h e l l , Margaret; "A Delinquent Adolescent", i n Precocious Adolescence i n Wartime, P.S.A.A., New York, 1944. Reprinted from The Family, May, 1944. Overton, A l i c e ; "Serving Families--Who Don't Want Help", Social Casework, July, 1953, F.S.A.A., New York. Ross, Helen; "The Caseworker and the Adolescent", The  Family, November, 1941, F.S.A.A., New York. Sapir, Jean V.; "Relationship Factors i n the Treatment of the Alcoholic, Social Casework, July, 1953, P.S.A.A., New York. F ' Townsend, Gladys E.; '"Short Term Casework with Clients Under Stress", Social Casework, November, 1953, F.S.A.A., New Yovk~. 

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