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Parental resistance in child guidance casework : an analysis of initial resistance manifested by parents… Kennedy, Ramona Frances 1957

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PARENTAL RESISTANCE IN CHILD GUIDANCE CASEWORK An analysis of i n i t i a l resistance manifested by-parents and the relation to casework services for disturbed ohildren, based on Child Guidance Clinic cases, Greater Vancouver, 1954. by RAMONA FRANCES KENNEDY Thesi3 Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the Sohool of Sooial Work Accepted as conforming to the standard required for the degree of Master of Sooial Work Sohool of Sooial Tfork 1957 The University of British Columbia i i i Abstract A pertinent problem in child guidance settings is the apparent i n a b i l i t y of a considerable number of parents to involve themselves in treatment. This results in seriously limiting the amount of help that can be given to the child, or results in the parents withdrawing from the agency leaving the problem untouched. It was therefore considered important to attempt to isolate resistance, as manifested by parents, to casework services during the intake study. Some of the causative factors in resistance are discussed in general terms, as background. A small group of cases (6) were then chosen for detailed examination. In a l l of these, a high degree of resistance was manifested. The defense mechanisms used to manifest resist-ance are described in general, and analysed in the specific cases. Sk i l l s and techniques which the social worker used to decrease i n i t i a l resistance were then tabulated; and from these certain common denominators became evident. The findings indicate a need for some refinement of intake procedures. There is evidently need also for greater effort on the part of social workers to decrease i n i t i a l resistance, since the capacity of parents to involve themselves in treatment appears to be dependent upon the favorable conditions created for them by the intake worker. Resistance is a complex phenomenon however, and demands further research. In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available f o r reference and study. I further agree that permission f o r extensive copying of t h i s thesis for scholarly purposes may be granted by the Head of my Department or by h i s representative. I t i s under-stood that copying or publication of th i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Aa^J ZQLJL The University of B r i t i s h Columbia, Vancouver $, Canada. Date £CMIA> 9,/9 s 7  TABLE OF CONTENTS i i Page Chapter 1. Resistance and the Child Guidance Setting 1 Child guidanoe cl i n i c s : referrals, intake screening, intake conference, and case planning. Resistance as manifested in withdrawal from service; its significance to the clients and to the agenoy. Relation of resistance to human behaviour: with illus t r a t i v e material. Ways of handling resistance. Transference i n resistance. Chapter 2. Manifestations of Resistance, and the Sooial  Work Approach Selection of sample cases. Patterns of decreasing intensity. Limitations of the study. A descriptive analysis (six cases): manifestations of resistance; social v^ork s k i l l s and techniques used in decreasing resistance. 27 Chapter 3. S k i l l s and Techniques for Decreasing Resistance 75 The specific activity of the worker. Skills, methods and techniques used in those cases where decreasing resistance was evident. Conclusions. Chapter 4. The Findings and their Implications.... , 84 Findings of the study and their significance. The need for refinement of intake procedures. The apparent significance for decreasing resistance of clients in other agencies. The needs for further study. TABLES: 1. Tabulation of features of the worker's activity, 2. Summarized features of the worker's activity... 82 83 XV ACKNOWLEDGEMENTS The writer wishes to acknowledge indebtedness to Dr. U.P. Byrne, Director of the Child Guidanoe Clinic, for permission to use c l i n i c records for research purposes. Special acknowledgement is made to Mrs. Estelle Chave, Supervisor, who provided the inspiration for the study, and who decreased my i n i t i a l resistance to i t ; to Dr. Leonard Marsh of the Faculty of the School of Social Work, for his relevant suggestions; to Mr. Adrian Marriage, of the Faoulty of the School of Social Work, for his many helpful criticisms and suggestions; and especially to Miss Frances McCubbin, also of the Faculty, without whose competent and confident guidance the study might not have been completed. * * * * * * V PARENTAL RESISTANCE IN CHILD GUIDANCE CASEWORK An analysis of i n i t i a l resistance manifested by parents and the relation to casework services for disturbed children, based on Child Guidance Clinic cases, Greater Vanoouver, 1954. CHAPTER I RESISTANCE AND THE CHILD GUIDANCE SETTING On t h i s continent, p s y c h i a t r i c c l i n i c s have developed i n three major stages. The f i r s t of these was the e s t a b l i s h -ment of c l i n i c s connected with mental h o s p i t a l s or i n s t i t u -tions f o r the feebleminded. The second development occurred as a m u l t i - d i s c i p l i n e d approach was taken to the causation and treatment of juvenile delinquency. The f i n a l phase came when i t was recognized that predominantly normal c h i l d r e n can ben e f i t from p s y c h i a t r i c services."*" We now have c l i n i c s that give out-patient services to disturbed c h i l d r e n and these c l i n i c s are described as "a community agency i n which s p e c i a l -ized professions combine t h e i r knowledge i n an attempt to employ the resources of a community to meet the problems of ch i l d r e n who are poorly adjusted to t h e i r environment or have 2 u n s a t i s f i e d inner needs." The c h i l d guidance movement created and encouraged the team approach to problems. At f i r s t , the team members: the p s y c h i a t r i s t , the psychologist, the pu b l i c health nurse, and the s o c i a l worker proceeded independently; l a t e r they merged t h e i r thinking i n t o a coordinated approach to treatment. At f i r s t , treatment consisted of e f f e c t i n g changes i n the c h i l d ' s environment, such as changing h i s school or neighbour-"^Fogarty, Patrick, M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, 195^, Relation of Children's Disorders to Limiting;  Parental Influences. Ch. 1, p.1. p Recording Committee Notes, 1956, C h i l d Guidance C l i n i c , Burnaby, B r i t i s h Columbia. (June) p . l . hood, and the use of such methods as advice-giving, and remedial educational help. As i t was r e a l i z e d that a great part of behavior has i t s o r i g i n i n unconscious f e e l i n g s , i t became c l e a r why so much of the advice given f a i l e d to b r i n g success i n c l i n i c cases. Advances i n psycho-analytic thinking made a deep imprint on c h i l d guidance methods. The i n s p i r e d leadership of Adolf Meyer had already encouraged a dynamic approach to problems, that i s , an exam-i n a t i o n of a l l the f a c t o r s i n the s i t u a t i o n , which might be cont r i b u t i n g to the problem. The primary focus was changed from the c h i l d to h i s family, p a r t i c u l a r l y the i n t e r a c t i o n of family members upon each other and i n t h e i r community. C h i l d Guidance c l i n i c s i n B r i t i s h Columbia The p r o v i n c i a l C h i l d Guidance C l i n i c i n B r i t i s h . . Columbia was opened i n 1 9 3 2 i n Vancouver. There had been an evident community need f o r such a c l i n i c and i t came into being through the stimulus of the National Committee f o r Mental Hygiene. At f i r s t the c l i n i c provided mainly a diagnostic service f o r other s o c i a l agencies. Later, other functions were added such as t r a i n i n g of p r o f e s s i o n a l s t a f f , education 1 of community and research. The inc r e a s i n g need f o r the services of the c l i n i c made the expansion of s t a f f and f a c i l i t i e s necessary. The present s t a t i o n a r y c l i n i c on the "^Roberts, E.M., M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1 9 4 - 9 , Mental Health C l i n i c a l Services describes the h i s t o r y and function of t h i s c l i n i c i n d e t a i l . Coyle, P h y l l i s , M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, T r a v e l l i n g P s y c h i a t r i c S e r v i c e s , describes t r a v e l l i n g c l i n i c s i n d e t a i l . mainland i s located i n a new b u i l d i n g i n Burnaby. Its p r o f e s s i o n a l s t a f f has been expanded u n t i l there are now three p s y c h i a t r i s t s , three nurses, f i v e psychologists, t h i r t e e n s o c i a l workers, and one speech t h e r a p i s t . The t r a v e l l i n g c l i n i c has a-team c o n s i s t i n g of a p s y c h i a t r i s t and a s o c i a l worker, and obtains the services of a nurse and psychologist from the stationary c l i n i c . This t r a v e l l i n g c l i n i c team v i s i t s towns i n o u t l y i n g areas of the province. V i c t o r i a also has a st a t i o n a r y and a t r a v e l l i n g c l i n i c , which serve c l i e n t s on Vancouver Island. Description of r e f e r r a l s and service Cases are r e f e r r e d to these c l i n i c s from many sources: s o c i a l agencies, schools, courts, p u b l i c health nurses, doctors a l t e r n a t e l y , the parent may come d i r e c t l y to the c l i n i c to ask f o r help. In the l a t t e r instance, the i n i t i a l contact i s most frequently a telephone c a l l at which time s t a t i s t i c a l informa-t i o n i s taken by a s o c i a l worker. Later, a worker from the intake s e c t i o n i n the agency arranges an o f f i c e interview at the convenience of the c l i e n t . In t h i s interview, parents are encouraged to present the problem and i t s causes as they see them and indicate i n what way they expect the agency to help. The f u n c t i o n of the agency i s explained, and i f the case comes within the scope of agency function, the case i s opened and the intake study begun. Cases i n which the problem i s not "^Beck, Dorothy, M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954-> Resistance of the Adolescent to Casework  Services, describes these services i n d e t a i l . - 4 -located i n the par e n t - c h i l d r e l a t i o n s h i p are r e f e r r e d to other agencies. During the intake study, the s o c i a l worker sees each parent at l e a s t once, sometimes more. The case i s then presented at an intake conference and o f f i c i a l l y accepted f o r service by the c l i n i c team when t h i s i s appropriate. A plan-ning conference follows and appointments are scheduled a month or more i n advance, f o r the c h i l d to see the psychologist f o r psychometric t e s t i n g and p e r s o n a l i t y evaluation, and f o r both parents and c h i l d to see the p s y c h i a t r i s t and nurse. A p h y s i c a l examination of the c h i l d i s completed, and the p s y c h i a t r i s t and nurse make a psycho-social evaluation of the c h i l d and the family, and as much of the family i n t e r - a c t i o n as can be assessed at that time. When there i s a speech d i f f i c u l t y , the c h i l d may also be r e f e r r e d to the speech therapist f o r assess-ment. In the meantime, the s o c i a l worker c a r r i e s on a serie s of interviews, mainly with the parents, but also with such c o l l a t e r a l sources as the school and the doctor, when permiss-i o n to make such contacts has been given by the c l i e n t s . A home v i s i t i s made r o u t i n e l y i n order to observe family i n t e r -a c t i o n i n a f a m i l i a r s e t t i n g . A l l these findings are part of a diagnostic evaluation which the c l i n i c team shares at the diagnostic conference. Here i t i s decided who w i l l work with the family and treatment focus and goals are established. This completes the intake study. Diagnostic f i n d i n g s are interpreted to the parents, and c e r t a i n recommendations are made. Many cases require that - 5 -the c h i l d be seen i n a s e r i e s of play interviews^which are designed to release f e e l i n g s , c l e a r up confusions the c h i l d may have, resolve g u i l t f e e l i n g s , and i n general, enable him to experience the healing q u a l i t i e s of a r e l a t i o n s h i p with the s o c i a l worker who accepts the c h i l d as he i s and provides as permissive an atmosphere as r e a l i s t i c a l l y p o s s i b l e . In those cases where i t i s considered that a change i n the a t t i t u d e of the parents would br i n g an almost immediate change i n the c h i l d ' s behaviour, play interviews are not required and the parents are seen e x c l u s i v e l y . There are times when the p s y c h i a t r i s t provides t r e a t -ment f o r one or both parents depending upon the nature and s e v e r i t y of the problem. When i t i s simply a matter of re-education of the parents i n a p a r t i c u l a r area of c h i l d care, the public health nurse may continue to see the family. Usually, however, the s o c i a l worker c a r r i e s on treatment with consultation from the p s y c h i a t r i s t . In addition, the intake worker has made use of an early t e n t a t i v e diagnosis so that a l l contact with the parents from the f i r s t interview has treatment implications. Resistance and withdrawal from treatment In c h i l d guidance work, there are more cases needing 1 Mackenzie, Budd C., M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, The Play Interview as a S o c i a l Work Technique i n a  C h i l d Guidance Setting, 1956» describes and defines play i n t e r -viewing methods i n d e t a i l . His d e f i n i t i o n , p.50, states: "The play interview i s a s o c i a l work technique when the play a c t i v i t y i n c l u d i n g the c h i l d ' s v e r b a l i z a t i o n s , i s d i r e c t e d and interpreted according to the t h e o r e t i c a l assumptions underlying s o c i a l work techniques." - 6 -help than can be handled by the a v a i l a b l e personnel and f a c i l i t i e s . At the Burnaby c l i n i c , there i s often a waiting period of one year between the intake study and the treatment period. Although exceptions are made f o r cases where immediate at t e n t i o n seems a necessity, a l l cases waiting would benefit from immediate help. The sooner i t i s given, the more p o s s i -b i l i t y there i s f o r growth and change i n the c h i l d . Many parents withdraw a f t e r much work has been done, leaving the problem untouched. This i s extremely unfortunate f o r both the parent and f o r the c h i l d needing help. The unsolved problems of childhood create problems f o r the i n d i v i d u a l to some degree i n l a t e r l i f e as well as d i s t u r b i n g every member of h i s family and decreasing the c o n t r i b u t i o n that these i n d i v i d u a l s can make toward t h e i r own and the community's well being. Administratively, withdrawals are i n e f f i c i e n t , since considerable p r o f e s s i o n a l e f f o r t and time have been given to people who have been unable to use them. There i s a need to examine the reasons f o r parents' withdrawal from the services at the c l i n i c , and research i n t h i s area i s being c a r r i e d out at the present time. Many c l i e n t s continue to come to c l i n i c but no change i n the s i t u a t i o n occurs and the problem remains untouched. Again, services are being given i n a way which i s ad m i n i s t r a t i v -ely unsound. This s i t u a t i o n - p o i n t s out a need f o r improved diagnostic and treatment s k i l l s i n order that the "un-coopera-t i v e " or r e s i s t i n g c l i e n t s can p a r t i c i p a t e i n treatment to such an extent that they can b e n e f i t from the service offered by the agency. _ 7 -Frame of Reference: A theory of p e r s o n a l i t y organization When a person or force i n the environment stimulates an i n d i v i d u a l to change customary ways of behaving, another force i s set i n motion which counter-acts to some degree the stimulus to grow and change. The i n d i v i d u a l i s then caught i n a struggle between hi s wish to grow and change and h i s unwillingness to do so. This unwillingness, or the i n d i v i d u a l ' s f a i l u r e to p a r t i c i p a t e i n a way which w i l l produce growth or change, has been given the name of resistance. I t i s not possible to separate resistance as an e n t i t y from the behaviour of an i n d i v i d u a l because i t i s an ever changing element i n the i n t e r - a c t i o n of one i n d i v i d u a l to another. The d i f f i c u l t i e s involved i n conceiving of such a dynamic concept, p o s s i b l y account f o r the d i f f e r e n t views regarding resistance which are expressed by the diagnostic and f u n c t i o n a l schools of s o c i a l work. The diagnostic group views p e r s o n a l i t y organization according to c e r t a i n tenets which have a Freudian b a s i s . The i n s t i n c t u a l drives and impulses w i t h i n the i n d i v i d u a l are r e f e r r e d to as the l i b i d o of the i n d i v i d u a l . The i d part of p e r s o n a l i t y r e f e r s to a l l the i n s t i n c t u a l drives which the i n d i v i d u a l possesses, the ego i s thought to be the more organized part of the i d . It i s believed that as the c h i l d grows, the ego part of the p e r s o n a l i t y , holding the cental p o s i t i o n i n the p e r s o n a l i t y , expands and grows according to the favorable course of the person's psycho-social development. The ego's functions are conceived of as the perception of - 8 -r e a l i t y and the f u r t h e r t e s t i n g of r e a l i t y to v e r i f y o r i g i n a l perceptions, making judgements on the basis of what i s per-ceived, and organizing, planning and executing actions appropriate with the inner needs of the i n d i v i d u a l and outer r e a l i t y . S e l f preservation i s then thought to be a f u n c t i o n of the ego. ^ The strength of the ego i s considered, to be a v a r i a b l e f a c t o r determined by inner and outer pressures on the i n d i v i d u a l . It i s believed that the i n d i v i d u a l can permanently b e n e f i t from goal d i r e c t e d treatment which aims at lessening inner or outer pressures. The super ego as a part of person-a l i t y i s thought to be the incorporated admonitions (both verbal and implied) of the parent or parent f i g u r e s i n the c h i l d ' s l i f e . As a r e s u l t of the wishes of these parental f i g u r e s , and the demands of r e a l i t y , the c h i l d must give up c e r t a i n i d wishes because of the wish to r e t a i n the love of the parent and through f e a r of parental disapproval, or punishment. The c h i l d pushes these disapproved impulses from conscious awareness, or represses them. The c h i l d ' s incorpor-ated ego or conscience then requires a permanent repression of the impulse, unless l a t e r changes take place w i t h i n the p e r s o n a l i t y . If the c h i l d f i n d s other ways compatible with r e a l i t y , of meeting the need which the o r i g i n a l i d impulse created, which was i n c o n f l i c t with the superego, a successful repression has taken place and a l l i s w e l l . I f the c h i l d does "*"The drive f o r s e l f preservation, and f o r growth and exploration i s thought to be a u n i v e r s a l c h a r a c t e r i s t i c of human beings. - 9 -not f i n d other ways of expressing the i d impulse, a c o n f l i c t i s set i n motion which requires a constant expenditure of e f f o r t on the part of the ego to keep the i d impulse from being expressed i n a d i r e c t way, and to keep the c o n f l i c t from con-scious awareness. The ego makes and keeps c e r t a i n r u l e s which are unconscious, but which serve to keep the disagreeable impulses from awareness. Individuals, then, develop c e r t a i n c h a r a c t e r i s t i c ways of perceiving and behaving which meet t h e i r needs to some degree and which protect t h e i r concept of s e l f . Certain a c t i v i t i e s developed by the ego f o r adaptation and pr o t e c t i o n are r e f e r r e d to as defense mechanisms. These represent the ego's active e f f o r t s to avoid f a c i n g unacceptable ideas which e a r l i e r i t had succeeded i n repressing, hence permitting the i n d i v i d u a l to maintain s u f f i c i e n t psychic equ i l i b r i u m to func t i o n with some degree of e f f i c i e n c y i n h i s environment. The person i s some- -what apprehensive about anything which disturbs t h i s psychic balance, and any stimulus which requires a change i n at t i t u d e does di s t u r b the balance to some degree. It follows that any-d i r e c t a c t i o n which i s aimed at the ego's defensive measures w i l l u s u a l l y r e s u l t i n greater defensive a c t i o n being taken, whatever form i t may take. Resistance: The operation of defense mechanisms The ego's e f f o r t s to avoid f a c i n g an unpleasant i d impulse or something which reminds the i n d i v i d u a l of the impulse which i s i n c o n f l i c t with the superego, and the r e s u l t i n g i n t e r p l a y of various defense mechanisms may be -10-recognized as resistance by the outsider who i s t r y i n g to influence the i n d i v i d u a l . As has been stated, the phenomenon of resistance i s not a separate e n t i t y , but one which operates among other aspects of behaviour. It i s po s s i b l e to i d e n t i f y manifesta-tions of resistance of an i n d i v i d u a l i n the i n t e r a c t i o n which takes place with another person. The i n d i v i d u a l w i l l not be aware that he i s using defensive measures nor w i l l he be aware of the reasons he needs to act i n t h i s p a r t i c u l a r way. The i n d i v i d u a l may not only exclude the p a i n f u l impulse from conscious awareness, or repress i t , but may project the wish or inadequacy unto another object or person. The i n d i v i d u a l w i l l then behave as though t h i s other object or person would demonstrate the objectionable behaviour toward him. For example: A mother may pro j e c t her f e e l i n g of r e j e c t i o n and r e s u l t i n g h o s t i l i t y unto the s o c i a l worker, or the agency, when there i s no basis i n r e a l i t y , and then behave as though the s o c i a l worker were r e j e c t i n g her. This may be evident i n overt expressions of h o s t i l i t y toward the s o c i a l worker or the agency which are not reasonable. Parents may proj e c t the blame f o r t h e i r c h i l d ' s d i f f i c u l t y upon some r e l a t i v e and thus avoid f a c i n g t h e i r own involvement i n the problem. Sometimes, a parent may pr o j e c t the blame f o r the problem unto some aspect of the c h i l d ' s c o n s t i t u t i o n a l makeup; again there i s avoidance of r e s p o n s i b i l i t y . In such a case, the s o c i a l worker would increase the resistance i f she were to challenge the v a l i d i t y of the parent's b e l i e f . - 11 -The parent may use the mechanism of i n t r o j e c t i o n by unconsciously incorporating the emotional a t t i t u d e , wishes, the p r o h i b i t i o n s or the i d e a l s of another person. This mechanism i s used by the young c h i l d who wishes to swallow objects as an expression of love. As the ego develops and r e a l i z e s that incorporation destroys objects i n the outside world, the ego learns to use i n ^ b j e c t i o n f o r h o s t i l e purposes. Extremely c r i t i c a l a t t i t u d e s or sarcasm are examples of such i n t r o j e c t i o n . The i n d i v i d u a l may use i d e n t i f i c a t i o n as a mechanism of defense. An i d e n t i f i c a t i o n with the aggressor involves incorporating the feared person's or object's a t t r i b u t e s , and then behaving as i f the i n d i v i d u a l a c t u a l l y possessed the q u a l i t i e s so incorporated. Frequently, a c h i l d i n whose family there i s considerable s t r i f e , w i l l i d e n t i f y with the most punitive parent as a defense against h i s fe a r s . When an i n d i v i d u a l uses the defense of r e a c t i o n forma-t i o n , the unpleasant idea i s repressed, and then to secure the repression, c e r t a i n a t t i t u d e s and i n t e r e s t s are developed which are the opposite of the unconscious wish. Behaviour developed i n t h i s way becomes a part of the p e r s o n a l i t y structure and can be recognized because of i t s r i g i d i t y or inappropriateness. For example: The parent who d i d not want her c h i l d w i l l u s u a l l y have to repress such a p a i n f u l wish, and then may react by being always thoughtful, p r o t e c t i v e , and kind to t h i s c h i l d . The inappropriateness may become evident by the f a i l u r e of the parent to d i s c i p l i n e the c h i l d - 12 -when i t i s necessary. A re a c t i o n formation a f f e c t i n g the whole p e r s o n a l i t y structure i s evident when the i n d i v i d u a l has been forced to repress a l l angry f e e l i n g s and has then reacted with p o l i t e kind behaviour. The inappropriateness of t h i s response and the r i g i d r e p e t i t i o n of i t i n d i c a t e a reaction formation. Using the mechanism of undoing, the i n d i v i d u a l develops a reaction formation but goes one step f u r t h e r and does something p o s i t i v e . The person attempts to undo or a b o l i s h the past experience or impression by repressing t h i s f e e l i n g , and developing a form of behaviour which symbolically i s the opposite of the behaviour which was experienced as p a i n f u l . For example: The parent whose own l i f e was fraught with the parents' m a r i t a l d i f f i c u l t y , where the mother neglected the father and lavished a t t e n t i o n on the c h i l d r e n may react by doing the opposite i n her own marriage. She may be constantly t r y i n g to "undo" mother's neglect of father, by being overly attentive to her husband's needs, to the neglect of her c h i l d r e n . Resistance could be increased i n t h i s instance i f the worker were to turn a t t e n t i o n to the needs of the c h i l d r e n . When the emotional value attached to one idea or person i s suppressed, i t frequently/bursts f o r t h against another idea or person. For example: When a parent has suppressed anger toward her own mother, the anger may be d i s -placed unto one of her.children. The i r r i t a t i n g mistakes which the c h i l d may make are then unconsciously looked forward - 13 -to, and i n t h i s way are provoked by the parent, since they provide a seemingly acceptable release of the parent's h o s t i l i t y . The parent may then consciously reason that she i s angry with the c h i l d because of the. i n c o r r e c t behaviour. The emotional f e e l i n g associated with a p a i n f u l experience may be l o s t to awareness or i s o l a t e d . In such a case, the parent may i n d i c a t e an i n t e l l e c t u a l grasp of a d i f f i c u l t y experienced yet be unable to change i n a t t i t u d e or behaviour. In t h i s case, the a f f e c t which the parent expresses i s not appropriate with the meaning of the experience to her. An unpleasant f a c t may be denied and acknowledged a l t e r n a t e l y . In t h i s p a r t i a l denial of r e a l i t y , the ego i s involved i n a struggle to repress the p a i n f u l idea but i s only p a r t i a l l y successful, yet f i n d s no substitute idea or ac t i o n . Denial of a p a i n f u l f a c t can be accomplished by s u b s t i t u t i n g e i t h e r a phantasy or some word or act designed to lessen the i n d i v i d u a l ' s fear. The parent who has requested help from the c h i l d guidance agency may l a t e r have unusual d i f f i c u l t y i n f i n d i n g time or transportation to see the s o c i a l worker. The parent may be h a b i t u a l l y l a t e f o r appointments, or may cancel appointments without v a l i d reason. These manifestations of resistance may indicate that the parent i s avoiding the pain of f a c i n g the problem. This i s r e a l l y a preliminary stage of defense. The parent may refuse to give information which i s relevant, or may t a l k about i r r e l e v a n t matters. This again ind i c a t e s an avoidance of the p a i n f u l subject of the problem. - 14 -The parent may avoid g e t t i n g into the deeper causes of the d i f f i c u l t y by i n s i s t i n g that the c h i l d ' s behaviour has improved. This appears to be an attempt to avoid being involved i n the casework interviews, through the use of d e n i a l ; and may occur at any time a f t e r the intake interview, or at any stage i n treatment. When the de n i a l means that the parent plans to withdraw from the agency, i t i s h e l p f u l to ask the parent what the o r i g i n a l problem was, exactly what has changed and what remains unchanged. I f t h i s i s done i n a way which ind i c a t e s the s o c i a l worker's concern f o r the parent, and the worker's wish to be h e l p f u l , i t i s frequently reassuring to the parent. A l l of the defenses "^involve a denial or d i s t o r t i o n of r e a l i t y to some degree. Greater defensive a c t i o n or increased resistance may be manifested i f the s o c i a l worker t r i e s to break down the defenses of the parent and makes her face the unpleasant r e a l i t y too soon. Some Causative Factors Underlying Marked Resistance Although a l l parents who come to a c h i l d guidance c l i n i c f o r help w i l l manifest resistance to some degree, there are some parents who f i n d extreme d i f f i c u l t y i n i n v o l v i n g them-selves i n the treatment s i t u a t i o n . The i n t e n s i t y of t h e i r "^Freud, Anna, The Ego and the Mechanisms of Defense, International U n i v e r s i t i e s Press Inc., New York, pages 30-189» Fen i c h e l , Otto, The Psychoanalytic Theory of Neurosis, W.W. Norton & Co. Inc., New York, pages 140 - 167. Menninger, William, Taken from a paper edited by the School of S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia, t i t l e d Fundamental^ of Psychiatry. . TThe material describing defense mechanisms was taken from these sources. - 1 5 -problems as well as t h e i r ego-strengths i n perc e i v i n g and dealing with them appear to have a r e l a t i o n s h i p to the degree of resistance manifested. Flores^studied resistance as manifested by mothers coming to a c h i l d guidance c l i n i c , from the point of view that resistance i s an i n d i c a t o r of motivation. I t was found that i n the majority of cases, some p r e c i p i t a t i n g f a c t o r had increased the i n t e n s i t y of the problem, and therefore s a t i s -f a c t i o n s with e x i s t i n g conditions had diminished. The mother was then motivated to seek help. F l o r e s noted that i n a s i g n i f i c a n t number of cases where parents withdrew from the agency, the problem had increased i n i n t e n s i t y to a marked degree. It was thought that i n these cases, the mother was extremely anxious and f e a r f u l regarding the extent of her con-t r i b u t i o n to the d i f f i c u l t y . Her ego-strengths were then thought to be strong enough to enable her to continue i n v o l v i n g h e r s e l f i n the casework interviews which would uncover her part i n the d i f f i c u l t y . Another view of the underlying causes of resistance p to treatment by the adolescent was taken by Beck who I d e n t i -f i e d f i v e major diagnoses: 1 . D i f f i c u l t i e s i n achieving emancipation from parents. 2. D i f f i c u l t i e s i n r e l a t i n g to people. 3 - Unresolved oedipal c o n f l i c t ; and a combination of these. " LB ,lores, Helen, M.S.W. Thesis, Smith College Studies, 1 9 5 4 . Resistance as an Indicator of Motivation - 1954-* P«35« 2 Beck, Dorothy, M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1954-* Resistance of the Adolescent to Casework Services, Ch. 3 , p. 6 3 - 9 3 . - 16 -4. D i f f i c u l t i e s i n achieving emancipation from parents and i n the a b i l i t y to r e l a t e to people. 5. D i f f i c u l t i e s i n emancipation from parents and with oedipal c o n f l i c t s . It may be assumed that the parent with unsolved d i f f i c u l t i e s i n adolescence would s t i l l be s t r u g g l i n g with the underlying d i f f i c u l t y . It i s thought that t h i s would increase or even create d i f f i c u l t i e s i n the p a r e n t - c h i l d r e l a t i o n s h i p . The i n t e n s i t y of these d i f f i c u l t i e s appears to be a f a c t o r i n whether or not the parent continues to come to the agency. In addition, these underlying d i f f i c u l t i e s would a f f e c t to a considerable degree the kind of r e l a t i o n s h i p the parent could form with the worker, and the i n t e n s i t y and the resistance manifested by the parent. The parent who hesitates to involve h e r s e l f at a l l i n the services of the agency presents a challenge to the s t a f f of the agency who would l i k e to use the a v a i l a b l e resources to help parents and c h i l d r e n r e a l i z e t h e i r p o t e n t i a l f o r growth and well-being. It i s generally recognized that f o r any permanent and s i g n i f i c a n t change to take Iplace i n the c h i l d ' s behaviour there must be a corresponding change, however s l i g h t , i n the behaviour of the parent. Involving the parent i n treatment i s therefore an i n t e g r a l p a r t of the process of helping the c h i l d who has psychological d i f f i c u l t i e s . Some Ways of Handling Resistance The worker's f u l l explanation of agency f u n c t i o n and ways i n which i t i s c a r r i e d out provides the framework f o r the ^Hamilton, Gordon, Psychotherapy i n C h i l d Guidance, Columbia U n i v e r s i t y Press, New York, 1947, p. 282. - 17 -i n t e r - a c t i o n between the c l i e n t and the worker. Parents need to be encouraged to express t h e i r expectations about the service they seek, and how t h i s d i f f e r s from the service a c t u a l l y given. The non-judgemental at t i t u d e of the s o c i a l worker should provide an atmosphere i n which even negative responses can be expressed. In f a c t , resistance has been viewed as the way i n which a c l i e n t reveals h i s negative f e e l i n g s . Parents frequently expect that when they contact a c h i l d guidance agency, work w i l l immediately be focused on the c h i l d . They may become apprehensive about the amount of time which i s taken by the s o c i a l worker to secure information about the family background, family a t t i t u d e s and way of l i f e . The s o c i a l worker needs to avoid proceeding only according to her own goals, and must take into account the parent's perception and f e e l i n g s . Frequently a parent w i l l contact the agency and then decide that the contact was r e a l l y unnecessary. The s o c i a l worker now has a knowledge of the presenting problem. Her p r o f e s s i o n a l s k i l l and knowledge give her the r i g h t and indeed, the o b l i g a t i o n , to ensure that these parents have enough knowledge of what i s involved i n the various courses of ac t i o n to enable them to make an i n t e l l i g e n t d e c i s i o n regarding t h e i r wish to help t h e i r c h i l d and themselves. Depending upon the s o c i a l worker's knowledge of the problem, she may wish to express d i r e c t p r o f e s s i o n a l concern f o r what may happen to the c h i l d i f the parents do not seek help. L i o n e l Lane has expressed the e f f e c t a worker's - 18 -a p p r o a c h may have upon a c l i e n t , i n t h i s way: "A c l i e n t ' s d e c i s i o n t o use h e l p w i l l he i n f l u e n c e d we b e l i e v e , by t h e degree o f f i r m n e s s and c o n v i c t i o n w i t h w h i c h we a p p r o a c h him. A l a c k o f c o n v i c t i o n i n o f f e r i n g s e r v i c e , as e v i d e n c e d b y o u r w i l l i n g n e s s t o w i t h d r a w a t t h e f i r s t r e b u f f , c a n o n l y l e a v e t h e p a r e n t more u n c o m f o r t a b l e i n c o n t i n u i n g i n an u n -h e a l t h y s i t u a t i o n . " The p a r e n t who has f a i r l y s e r i o u s d i f f i c u l t i e s w i t h a c h i l d w h i c h a r e i n p a r t e m o t i o n a l l y c a u s e d , u s u a l l y has some s e l f d oubt and l o w e r e d f e e l i n g s o f s e l f w o r t h . I n p a r t i c u l a r , t h e p a r e n t who has c o n t a c t e d t h e c l i n i c b e c a u s e o f t h e p r e s s u r e o f some o u t s i d e a u t h o r i t y i n t h e s i t u a t i o n s u c h as a d o c t o r , o r a t e a c h e r , w i l l f r e q u e n t l y have c o n t a c t e d t h e agency o u t o f a sense o f o b l i g a t i o n and may n o t be r e a d y t o use h e l p . I t may be s p e c u l a t e d t h a t t h e s e p a r e n t s have l o w e r ego s t r e n g t h s . T a n g i b l e p r o o f o f t h e s o c i a l w o r k e r ' s d e s i r e t o be o f h e l p c a n be d e m o n s t r a t e d b y making home v i s i t s and b y o f f e r i n g s p e c i a l l y t i m e d a p p o i n t m e n t s i f t h i s i s more c o n v e n i e n t f o r t h e c l i e n t . M aking s u r e t h a t e v e r y o n e d i r e c t l y c o n c e r n e d w i t h t h e c h i l d has an o p p o r t u n i t y t o see what i s i n v o l v e d and t o g i v e t h e i r c o n t r i b u t i o n , , i s a v i t a l p a r t o f t h e i n i t i a l work w i t h t h e c h i l d ' s f a m i l y . P o l l a c k g i v e s some i n d i c a t i o n o f t h e p o s s i b l e s i g n i f i c a n c e o f v i s i t i n g c o l l a t e r a l s o u r c e s : " E x t r a f a m i l i a l f a c t o r s c annot be d e a l t w i t h i n d e p e n d e n t l y f r o m f a m i l i a l f a c t o r s . I t i s j u s t i n t h e i r i n t e r - r e l a t i o n s h i p s t h a t t h e i r meaning c a n be f o u n d . The s o c i a l m a t r i x w i t h i n w h i c h o u r h e l p i n g e f f o r t s were t o r u n t h e i r c o u r s e , had t o be known, Lane, L i o n e l C., J o u r n a l o f S o c i a l Casework, V o l . 3 3 , F e b r u a r y 1952, p.65* " A g g r e s s i v e A p p r o a c h i n P r e v e n t i v e Case-work w i t h C h i l d r e n ' s P r o b l e m s . " 2 P o l l a c k , O t t o , I n t e g r a t i n g S o c i o l o g i c a l and P s y c h o a n a l y t i c  C o n c e p t s , R u s s e l Sage F o u n d a t i o n , New Y o r k , 1956, p.108 - I I I . - 1 9 -and i f unfavorable, re-structured so as to provide a favorable m i l i e u f o r therapy. In consequence, we found i t desirable to e s t a b l i s h contact with as many persons of importance i n the s p e c i f i c s i t u a -t i o n as possible and give them a frame of reference with which to view the therapy. Fathers, s i s t e r s , teachers, and physicians f e l l i n t o t h i s category. Even where our e f f o r t s to provide a. frame of reference were unsuccessful because of unconscious resistances, they d i d not prove useless. (These contacts) often made the d i f f e r e n c e between ge t t i n g a case into treatment and not g e t t i n g i t i n at a l l . " It would appear that there i s considerable value i n contacting not only the parent who comes i n i t i a l l y to the agency, but other people of importance i n the s i t u a t i o n as a means of decreasing the parent's resistance. Permission must be obtain-ed from! the parent before the worker may make these contacts, because of the s o c i a l worker's b e l i e f i n the c l i e n t ' s r i g h t to s e l f determination as a person of d i g n i t y and worth. Change and growth i n an i n d i v i d u a l i s thought to be influenced p r i m a r i l y though the medium of a meaningful r e l a t i o n -ship with another person."1" The s o c i a l worker o f f e r s a f r i e n d l y warm r e l a t i o n s h i p w i t h i n the l i m i t s of her p r o f e s s i o n a l r o l e . This kind of r e l a t i o n s h i p , offered with an acceptance of the c l i e n t as she i s , i s thought to ease fe a r s . To help r e s i s t a n t c l i e n t s , i t appears necessary to be able to see the problem as 2 they do. Charlotte Towle has stated i t i n t h i s way: "How do we get a person to accept a new under-standing of our s e r v i c e ? Through merely t e l l i n g him about i t , or through f i r s t understanding him? May he not become more receptive to understanding 1 This p r i n c i p l e has been taken from a mimeographed paper edited by Exner, Helen K., School of S o c i a l Work, U n i v e r s i t y of B r i t i s h Columbia, 1956. 2 Towle, Charlotte, S o c i a l Case Records from P s y c h i a t r i c C l i n i c s , The U n i v e r s i t y of Chicago Press, 1942, p. 25. - 20 -us, i n s o f a r as we have understood him? How do we get a person to r e l a t e himself d i f f e r e n t l y to hi s problem? By pressing him to look at i t from our angle or by looking at i t f i r s t from h i s angle? May he not be more prone to view the problem from another standpoint, i f we have viewed i t f i r s t with him from h i s standpoint?" The c l i e n t frequently has an amazing degree of i n t u i t i v e awareness of how well he i s understood. Genuine understanding promotes f e e l i n g s of s e c u r i t y . Willsnack has suggested that the r e s i s t a n t c l i e n t needs a s e c u r i t y r e l a t i o n -ship i n which the worker must duplicate to the extent permitted i n the s e t t i n g , the r o l e played by the e a r l i e r author of se c u r i t y i n the c l i e n t ' s l i f e . He believes that i f there was no r e a l i t y author, then the ro l e of the phantasied protector must be duplicated. 2 Flores points out a s i g n i f i c a n t occurence i n her findings about the resistance of t h i r t y - s i x mothers to case-work services. The mother was motivated to continue treatment when the worker recognized and handled the resistance when i t arose. This was apparently true, regardless of the way i n which the worker handled the resistance. It seems to ind i c a t e that the parent was helped to f e e l safe enough to express 3 negative f e e l i n g s and f e a r s . ^Beck s i g n i f i c a n t l y remarks i n her study of the r e s i s t a n t adolescent that there was a pattern of decreasing resistance i n those cases where the resistance was externalized i n some way. "'"Willsnack, William H. , Handling of Resistance i n S o c i a l Casework, p. 302, American Journal of Ortho Psychiatry, Vol 16, A p r i l , 1946. 2 ^Flores, Helen, op. c i t . , p. 35• Beck, Dorothy, op. c i t . , p. 59' - 21 -The separate i d e n t i t y of the s o c i a l worker who shares the parent's perspective, hut who gently adds another perspec-t i v e by comments and questions, helps the parent to see r e a l i t y with l e s s d i s t o r t i o n . The problem i s separated i n t o i t s various parts and examined with a view to discovering the t y p i c a l ways i n which the parent reacts and deciding the appropriateness and e f f i c i e n c y of the reactions. I f the parent believes the s o c i a l worker i s i n league with her p o s i t i v e goals of s a t i s f a c t i o n , she frequently i s able to decrease defensive a c t i o n enough to see and f e e l d i f f e r e n t l y about the problem. I d e n t i f i c a t i o n with the s o c i a l worker promotes ego growth i n the c l i e n t , o ften relaxes an overly s t r i c t superego. It may be added that to be i n league with the i n d i v i d u a l ' s p o s i t i v e goals of s a t i s f a c t i o n , the s o c i a l worker must have a knowledge of the p a r t i c u l a r c u l t u r a l group from which the i n d i v i d u a l comes. A suggestion which opposes a c u l t u r a l value may not only increase resistance, i t may be harmful to the parent, and to the c h i l d . The g i v i n g of help i n a r e l a t i o n s h i p which duplicates to some extent the p o s i t i v e elements of the parental r e l a t i o n -ship brings i n to the client-worker r e l a t i o n s h i p an element known as transference. Transference and Resistance Transference f e e l i n g s may be defined as l a r g e l y unconscious, remotely caused, i n f a n t i l e a t t i t u d e s which are a part of the worker-client r e l a t i o n s h i p . 'Part of the trans-ference w i l l be p o s i t i v e , corresponding p r i m a r i l y to the love - 22 -1 f e l t f o r the parental f i g u r e , (and somewhat changed by experiences with l a t e r f i g u r e s upon whom the e a r l i e r f i g u r e was projected); part of the transference w i l l be negative, corresponding to the hate and fear f e l t f o r the e a r l y f i g u r e , (and again somewhat changed by.experiences with l a t e r f i g u r e s on whom the early f i g u r e was projected).2 "Where i s so often the case, the c l i e n t ' s problem i s to a considerable degree an emotional problem, r e q u i r i n g f o r i t s s o l u t i o n some modification of h i s own a t t i t u d e s , transference tends to develop more r a p i d l y , or even to occur to a marked degree i n the i n i t i a l interview." 3 Even though the s o c i a l worker may be able to help the c l i e n t without knowing about transference, i t i s thought that understanding transference phenomena w i l l aid i n a more accurate and e a r l i e r obtained knowledge of the parent, and what i s needed to help her. I f transference develops i n the i n i t i a l interview, the s o c i a l worker must be a l e r t i n ensuring that the r e l a t i o n s h i p does not develop to the degree that the parent w i l l r e s i s t t r a n s f e r r i n g to another worker, should t h i s be necessary. In order to handle resistance s k i l l f u l l y , i t i s help-f u l f o r the worker to be aware of such transference manifest-ations as may be evidenced by seemingly casual comments. Eor example: "My neighbour i s always snooping i n t o my a f f a i r s , " warns the worker to go slowly i n securing information from the -1 I t i s recognized that transference elements e x i s t to some degree i n a l l r e l a t i o n s h i p s . 2 Garrett, Annette, The Worker-Client Relationship, Journal of Ortho Psychiatry, 194-9, Vol 19, p. 225. 3-—; Garrett, Annette, i b i d , p. 225. - 2 3 -parent, and to be e s p e c i a l l y c a r e f u l to explain the reasons f o r any questions which are asked. "My mother never understood me." warns the worker to make every e f f o r t to do so. "'""My husband i s always c r i t i c i z i n g my mother." warns the worker to make no comment which can be construed as a c r i t i c i s m of the mother, or a resistance w i l l be created. Resistance i s apparently increased by anything which duplicates the negative elements i n the c l i e n t ' s parental r e l a t i o n s h i p . Transference operates by the unconscious mechanisms of p r o j e c t i o n , and i n t r o j e c t i o n , or i d e n t i f i c a t i o n . Just as a c h i l d ' s a f f e c t i o n f o r her parents make her accept more w i l l i n g l y t h e i r suggestions, so do a c l i e n t ' s transference f e e l i n g s f o r the s o c i a l worker make her more w i l l i n g to accept suggestions. The att i t u d e s of the s o c i a l worker are e s p e c i a l l y therapeutic 2 because of t h i s . Garrett has in d i c a t e d the importance of the operation of transference i n the worker-client r e l a t i o n s h i p . "Transference i s not an end i n i t s e l f , but i t s operation whether c o n t r o l l e d by the caseworker or not, accounts f o r success i n those cases, where the c l i e n t ' s adjustment i s blocked not alone i n r e a l i t y , but at l e a s t i n part by emotional d i f f i c u l t i e s . Its operation accounts f o r many case-work f a i l u r e s , as i n those cases where the worker, unaware of i t s presence, f o s t e r s too much trans-ference too r a p i d l y , or f a i l s to develop enough to hold the c l i e n t through rough going." 3 During the intake study, i t i s possible that the s o c i a l worker, by the very process of going over the aspects of the problem, w i l l come close to uncovering material which the "^"Garrett, Annette, i b i d p. 226. 2 Garrett, Annette, i b i d p. 226. Garrett, Annette, i b i d , p. 231. - 24 -parent has attempted to keep repressed. Increased resistance may occur as a r e s u l t , and sometimes dis c u s s i o n around t h i s area w i l l have to be delayed u n t i l the parent f e e l s safer with the worker. The f a c t of the transference may create resistance i n that the c l i e n t may be rel&Otant to bring out any negative material f o r fear of l o s i n g the worker's respect. This can u s u a l l y be handled by t e n t a t i v e l y v e r b a l i z i n g the c l i e n t ' s f e a r and g i v i n g reassurance about i t . An extremely serious resistance could be created i f the transference develops to the point where unconscious unresolved problems begin to dominate, and be reproduced i n the interviews. This i s c a l l e d a transference neurosis, and although i t i s d e l i b e r a t e l y created i n a n a l y t i c a l treatment, i t i s e s s e n t i a l to avoid i t i n casework interviews. I t i s , therefore, important f o r the worker to know what increases and what d i l u t e s transference. In general, the d i s c u s s i o n of f a c t u a l m a t e r i a l , the r e l a t i n g of given information to the r e a l i t y s i t u a t i o n , and the use of generalizations tend to d i l u t e transference. The spacing of interviews and the use of the hour interview are also important. The.-discussion of emotional material, the use of p e r s o n a l i z a t i o n , and more frequent or longer interviews a l l tend to increase transference. Re sume It appears that i n order to handle the resistance Garrett, Annette, i b i d , p. 226. - 25 -which i s manifested during the intake study, the s o c i a l worker needs to make an i n d i v i d u a l assessment of the parent i n order to see the meaning of the resistance. The evidence indicates that every i n d i v i d u a l needs pro t e c t i v e defenses and that the r e s i s t a n t parent needs to experience the se c u r i t y of a sus-tained p o s i t i v e r e l a t i o n s h i p with the worker before the parent can give up enough defensive measures to p a r t i c i p a t e i n t r e a t -ment. The worker must move at the parent's pace. The r e s i s t -ance needs to be externalized i n some way, i f i t i s to be decreased. It i s apparent that the i n i t i a l steps taken i n a case are e s p e c i a l l y important and that resistance could be created by d u p l i c a t i n g former negative experiences which the parent has had, and about which she may e s p e c i a l l y be s e n s i t i v e . A strong enough r e l a t i o n s h i p must be developed to enable the parent to b r i n g out negative f e e l i n g s . Where resistance i s severe and p e r s i s t e n t , i t appears necessary to t e n t a t i v e l y verbalize the c l i e n t ' s f e a r and give r e a l i s t i c reassurance about i t . Making home v i s i t s , and c o l l a t e r a l v i s i t s are an e f f e c t i v e means of making the parent aware of what i s involved i n seeking or r e f u s i n g agency help, and also of demonstrating the worker's a b i l i t y and desire to be of help to the parent. It may be speculated that an ear l y recognition of resistance and i t s meaning w i l l be an important f a c t o r i n the a b i l i t y of the worker to decrease resistance to the point where the parent i s able to use help. It may also be speculated that a greater i n t e n s i t y of resistance w i l l be - 26 -manifested by the parent who contacts the agency because of the pressure of some outside a u t h o r i t a t i v e influence. There i s also a question regarding whether these more r e s i s t a n t parents are the ones who are experiencing greater d i f f i c u l t i e s i n t h e i r r e l a t i o n s h i p with t h e i r c h i l d r e n , and i f so, whether ' they are, therefore, i n greater need of help. In chapter two, the v a l i d i t y of some of these concepts w i l l be tested by an analysis of the resistance to casework service manifested by parents, and the a c t i v i t y of the worker i n decreasing the resistance to the degree that the parents and c h i l d were able to involve themselves i n treatment, and apparently benefit from i t . CHAPTER I I MANIFESTATIONS OE RESISTANCE AND THE SOCIAL WORK APPROACH The d e s c r i p t i v e analysis of s i x case records was undertaken i n order to discover the ways i n which a s o c i a l worker may help parents to accept and use the casework services given by a c h i l d guidance agency. It was recognized that many parents request help but l a t e r r e s i s t continuing contact with the c h i l d guidance agency, or i f they continue, they may r e s i s t i n v o l v i n g themselves i n the helping process offered by the agency. The analysis w i l l focus on the defense mechanisms used by parents to r e s i s t treatment, with the objective of i d e n t i f y i n g exactly how the worker responds to parents who manifest considerable r e s i s t -ance. It was thought that there p o s s i b l y existed a pattern of s o c i a l work methods and techniques which would be e f f e c t i v e i n decreasing i n i t i a l resistance to the extent that parents could involve themselves i n the helping process and ul t i m a t e l y b e n e f i t from i t . I n i t i a l resistance i s defined as resistance manifested during the intake study. S e l e c t i o n of Cases F o r t y - f i v e cases from the Burnaby C h i l d Guidance C l i n i c were reviewed i n order to s e l e c t s i x which conformed to the following c r i t e r i a : 1. There was evidence i n the record that at l e a s t one, but u s u a l l y both parents manifested a considerable degree of resistance to casework services. 2. A person with some recognized authority i n the community had recommended that the parents seek help from the c l i n i c . - 28 -3« I n i t i a l resistance was decreased to the degree that parents were able to involve themselves i n treatment. Involvment i s defined as p a r t i c i p a t i o n i n casework interviews which appeared to r e s u l t i n movement. Movement i s defined as any change i n the apparent w i l l i n g n e s s of the parent to p a r t i c i p a t e i n i n t e r -views i n addition to one of the following: (a) Any apparent change i n the a t t i t u d e of the parent towards the c h i l d . (b) Changes i n the parent's understanding of t h e i r own or the c h i l d ' s behaviour as evidenced by the parent's v e r b a l i z a t i o n s . (c) Changes i n the c h i l d ' s adaptive a b i l i t y as evidenced by b e t t e r school performance, etc. (d) Changes i n the c h i l d ' s d i s a b l i n g habits, such as improved s o c i a l r e l a t i o n s h i p s . 4. The worker's a c t i v i t y was recorded i n d e t a i l . Considerable d i f f i c u l t y was experienced i n f i n d i n g cases which conformed to these c r i t e r i a . During the review of cases, the impression was formed that approximately h a l f of the cases a u t h o r i t a t i v e l y r e f e r r e d to the c l i n i c i n some way, d i d not reach the point of diagnostic conference or c l i n i c team study and recommendations. These parents withdrew during the intake study. Another impression was formed that approx-imately h a l f of those parents who were given diagnostic i n t e r p r e t a t i o n and the c l i n i c team's recommendations f o r t r e a t -ment, d i d not return, and these cases were closed. This seemed to indicate that although parents have continued to p a r t i c i p a t e i n interviews, they may not have involved them-selves i n the helping process s u f f i c i e n t l y to b e n e f i t from i t . It i s recognized that c e r t a i n of these parents who withdrew may have been helped to some degree during the intake study i t s e l f ; that i s , they may have been given a " b r i e f s e r v i c e " kind of help, even though such a l i m i t e d goal was not the plan. In the majority of cases, i t appeared that f u r t h e r help was - 29 -needed, and case records c l e a r l y gave the c l i n i c teams' recommendations f o r continued s e r v i c e . This knowledge l e d to de f i n i n g the c r i t e r i o n of parent's having "involved themselves i n treatment" by i n d i c a t i o n of movement i n the case. The l i m i t a t i o n s of a s e l e c t i o n using t h i s c r i t e r i o n i s recognized; that i s , e f f e c t i v e s o c i a l work methods and techniques may have been used appropriately with the group of parents who withdrew a f t e r the intake study was completed. Other f a c t o r s may have influenced t h e i r withdrawal. For example: The waiting period between the intake study and the treatment period may have discouraged them; the necessary t r a n s f e r to another worker may be part of the d e c i s i o n not to continue. In addition, the i n t e n s i t y of the problem may have decreased to the point where overcoming a l l these other discouraging obstacles seemed to be l e s s rewarding than con-t i n u i n g with the lessened pressures of t h e i r present s i t u a t i o n . There i s i n d i c a t i o n i n the l i t e r a t u r e that i f the problem suddenly increases i n i n t e n s i t y , the r e s u l t i n g anxiety and g u i l t may prove too d i f f i c u l t f o r the parent to handle i n the casework s i t u a t i o n . This l a t t e r reason needs c l a r i f i c a t i o n , i n that the point at which the problem increases i n i n t e n s i t y i s important, that i s , i t may come at the time when parents begin to see how much of the d i f f i c u l t y they are creati n g , and before they have developed a strong enough r e l a t i o n s h i p with the s o c i a l worker to be sustained through t h i s upsetting experience. The assumption was, that i n s e l e c t i n g cases which - 30 -were a u t h o r i t a t i v e l y r e f e r r e d , the ego-strengths of the parents would not be as strong as those parents who lear n about the c l i n i c through t h e i r general knowledge of community resources and decide to seek help because of t h e i r own sharp perception of the i n t e n s i t y of the d i f f i c u l t y i n par e n t - c h i l d r e l a t i o n -ships; and t h e i r b e l i e f that seeking help i s a wise and a good thing f o r a parent to do. Exceptions to t h i s are recognized, because the former q u a l i t i e s may be present i n the parent who also consults the family doctor and i s then r e f e r r e d to the agency by him. If the assumption i s , on the whole, a correct one, the analysis of the worker's use of methods and tech-niques should be e s p e c i a l l y h e l p f u l because such parents would be a more d i f f i c u l t group to help than those who had greater ego-strengths. In any case, i t i s evident that much of the c l i n i c s t a f f ' s time, knowledge and s k i l l does not a i d t h i s group of parents who are ref e r r e d by some person with recog-nized authority i n the s i t u a t i o n . I f there are common techniques which are e f f e c t i v e i n decreasing the resistance of parents who have low ego-strengths, the recognition of these common denominators would lead to some refinement of the approach, diagnosis, and treatment given i n the intake period. Method In order to analyse the s i x cases i n a standardized manner, a schedule was designed to consolidate the main features of the case: the s t a t i s t i c a l data, the family c o n s t e l l a t i o n , the p e r s o n a l i t y of the parents, and the - 31 -resistance manifested. The worker's use of techniques was noted with reference to some of Glover's defined s o c i a l work 1 techniques; i n addition, c e r t a i n a c t i v i t y was recorded as i t occurred, such as extra home v i s i t s , and telephone c a l l s . The features of the worker's a c t i v i t y were recorded c h r o n o l o g i c a l l y except that no mention i s made of r e p e t i t i o n of the same feature unless i t was repeated a considerable number of times, i n which case i t was commented upon. The chronological order i s thought to have some s i g n i f i c a n c e because many authors have indi c a t e d that the i n i t i a l steps taken i n a case are frequently v i t a l steps i n determining how the c l i e n t w i l l see the agency service i n r e l a t i o n to her problem and her s e l f -image . Limitations of the S e l e c t i o n The s i x cases were selected at random from Burnaby C h i l d Guidance records from the year 1 9 5 4 . The s e l e c t i o n s are therefore not n e c e s s a r i l y representative of the parents who come to the agency having been r e f e r r e d by some person with authority i n the c l i e n t ' s s i t u a t i o n . A c r i t i c could reasonably say that the group of parents i n the s e l e c t i o n might have had the ego-strengths to make an improvement i n t h e i r family d i f f i c u l t y , regardless of the s o c i a l work techniques used by the s o c i a l worker. The worker's a c t i v i t y i n the s e l e c t i o n i s not n e c e s s a r i l y representative of the a c t i v i t y c a r r i e d out by s o c i a l workers i n the agency. I : Glover, Geoffrey, Casework Interviewing Methods i n a .Child Guidance Setting. M.S.W. Thesis, U.B.C, 1 9 5 1 , p.8 . - 32 -A more serious l i m i t a t i o n i s the i m p o s s i b i l i t y of r e a l l y separating resistance as an e n t i t y from the general behaviour of an i n d i v i d u a l , at any time, but p a r t i c u l a r l y i f the resistance i s covert. The worker's memory of what took place i n the interview, together with d i f f i c u l t y i n recording what happened places another l i m i t a t i o n on recognition of manifestations of resis t a n c e , and i d e n t i f i c a t i o n of s o c i a l work techniques used by the s o c i a l worker. It i s recognized that many workers do not record a l l of t h e i r a c t i v i t y i n a case. The analysis i s also l i m i t e d by personal judgment regarding what constitutes r e s i s t a n c e , and what a c t i v i t y of 1 2 the worker constitutes a p a r t i c u l a r s o c i a l work technique. The analysis of the s i x cases i s presented i n a de s c r i p t i v e manner with reference to schedule A. R e l i g i o n was omitted from the schedule because a l l of the parents i n the s e l e c t i o n were Protestant. R a c i a l o r i g i n was not included i n the schedule, but the selected group were a l l of B r i t i s h r a c i a l o r i g i n , with the exception of Case "D" where the r a c i a l o r i g i n was Swedish. A l l of the parents i n the selection -were born i n Canada. "*"The worker r e f e r s to the s o c i a l worker who i s responsible f o r casework services given during the intake study i n the c h i l d guidance c l i n i c - which w i l l be referre d to as the c l i n i c . 2 It i s recognized that the q u a l i t y of the r e l a t i o n s h i p offered by the worker cannot be assessed by reading a recording; the e s s e n t i a l s of the helping r e l a t i o n s h i p , the warmth and genuine l i k i n g of the worker f o r the c l i e n t cannot be accura-t e l y assessed by reading the case record. - 33 -Schedule A R e f e r r a l : C H I L D : Age: Sex: P o s i t i o n i n family: Presenting Problem: FAMILY. Occupation of father: Economic p o s i t i o n : Community p a r t i c i p a t i o n : M a r i t a l r e l a t i o n s h i p : MOTHER: Personality: Resistance manifested i n i n i t i a l interview: Resistance manifested i n subsequent interviews (or contacts): Defense mechanisms used (major ones): FATHER: Personality: Resistance manifested i n i n i t i a l interview: Resistance manifested i n subsequent interviews (or contacts): Defense mechanisms used (major ones): TEAM FINDINGS: Diagnosis and recommendations WORKER'S ACTIVITY: Indication of movement at the completion of intake study Indication of movement at point of closure. The "A"Case R e f e r r a l : Mother at the suggestion of the Doctor. CHILD: K i t t y i s a two and h a l f year o l d g i r l who i s the t h i r d c h i l d i n a family of four. She wakes often at night and screams f o r 15 to 20 minutes. She cannot sleep during the day and i s cranky and i r r i t a b l e . This behaviour began when she was nine months old. FAMILY: Mr. A i s 40 years old and i s a fireman who has an adequate income. He i s keenly i n t e r e s t e d i n h i s job and p a r t i c i p a t e s i n community a c t i v i t y where his knowledge of the job i s h e l p f u l i n educating others. He does not belong to any organized group. His only form of r e c r e a t i o n appears to be one night weekly sessions "with the boys", a group of h i s f r i e n d s . Mrs. A i s 37' years old and does not take part iin any s i m i l a r kind of outside a c t i v i t y . There i s very l i t t l e shared a c t i v i t y or recreation. They state that they have a good ma r i t a l adjustment, and that family a f f a i r s continue smoothly. They never quarrel, but they both state that there are a l o t of things which they keep to themselves i n order that the m a r i t a l r e l a t i o n s h i p w i l l continue without quarrels. A s i g n i f i c a n t health problem i s the d i f f i c u l t y which Mrs. A experienced a f t e r the b i r t h of K i t t y . The record only mentions that she was upset and had to be given sedation f o r four days. The doctor c a l l e d t h i s a post partum "near psychosis". K i t t y i s described as being very pale and l a c k i n g i n energy, but has no apparent p h y s i c a l problems. - 35 -MOTHER: She c a l l s h e r s e l f "a worrier". The record states that she was c o n t r o l l i n g i n the interview s i t u a t i o n . One other important person i n the s i t u a t i o n describes her as f a s t i d i o u s and p e r f e c t i o n i s t i c . Both parents gave i n d i c a t i o n that Mrs. A keeps the house and a l l four c h i l d r e n so neat and clean that neighbours remark on i t . The record gives the impression that mother does not express her f e e l i n g s e a s i l y . She i s seen as a r e l i a b l e person who centres her i n t e r e s t i n her own family, and does not s t r i v e f o r expression of i n t e r e s t or energy i n any other s i t u a t i o n . Her p e r s o n a l i t y apparently includes high standards of ri g h t and wrong and considerable energy i s devoted to maintaining them. In the i n i t i a l interview, Mrs. A r e s i s t e d by apologising f o r having contacted the c l i n i c and stated that she. f e l t f o o l i s h f o r making so much of the problem; she seemed to be implying that i t was not very serious. She stated that she would l i k e to wait a week or two before doing anything about f u r t h e r interviews. She said that K i t t y c e r t a i n l y d i d not lack love or attention. In subsequent interviews, Mrs. A manifested resistance by saying that K i t t y ' s screaming had stopped and mother d i d not see the need of having further interviews. The s o c i a l worker stated that i n the interview and i n other contacts, mother maintained control of the conversation and of future appointments. The major defense mechanism used i n the manifestation of resistance to services appeared to be denial of the -36 -seriousness of the problem and the need f o r help from the c l i n i c . Mrs A apparently had some c o n f l i c t over t h i s and was sometimes able to repress the unpleasantness and sometimes not able to do so. The problem appeared to be at a preconscious l e v e l s t ruggling into consciousness from time to time. The mother a c t u a l l y avoids the c l i n i c interviews and withdraws from contact f o r a period of time. FATHER: He i s a very energetic, t a l k a t i v e man, very active i n c e r t a i n areas, f o r example i n his job, and re l a t e d a c t i v i t i e s . He tends to avoid active p a r t i c i p a t i o n i n c e r t a i n aspects of family l i f e , f o r instance, according to h i s own and h i s wife's statements, he does not worry or even indicate much i n t e r e s t i n the children's problems, or i n dif f e r e n c e s a r i s i n g between him and h i s wife, although he does express a mild degree of i n t e r e s t i n them. The record reveals that he i s r e l i a b l e and has provided adequately f o r h i s family. It appears that h i s standards of cleanliness and neatness are more normal than those of Mrs. A. Their statements reveal that he does not express h i s f e e l i n g s e a s i l y . In the i n i t i a l interview, Mr. A manifested resistance by p a r t i c i p a t i n g to such a l i m i t e d degree that i t appeared that he was pro j e c t i n g a l l of the r e s p o n s i b i l i t y f o r the problem and what should be done about i t upon hi s wife. (In l a t e r interviews, he a c t u a l l y stated t h i s . ) In subsequent interviews, Mr. A manifested some resistance by t h i s same p r o j e c t i o n upon h i s wife of the major r e s p o n s i b i l i t y f o r the problem. He stated that he "would l i k e - 37 -help, but d i d not want to get too involved." He talked f o r a considerable length of time about c e r t a i n i n t e r e s t s he had which were unrelated to the problem. He said that he f e l t the family was fortunate, enumerated a l l the material things they possessed and said that he did not think that t h e i r problems were as serious as those of many other people; he thought h i s wife worried too much about them, and he i s concerned f o r her sake. The major defense mechanisms which Mr. A appeared to be using i n r e s i s t i n g any involvement i n seeking help were deni a l of the seriousness of the problem and p r o j e c t i o n unto his wife f o r the r e s p o n s i b i l i t y . He p a r t i c i p a t e d i n i n t e r -views as though the reason they were now contacting the c l i n i c was because Mrs. A worried too much, not because of the r e a l pain the c h i l d ' s problem was creating f o r the family, and f o r the c h i l d h e r s e l f . TEAM FINDINGS: K i t t y was seen as an over-indulged anxious c h i l d who has been c o n t r o l l e d to such an extent that she has no spontaneity. She was very u n f r i e n d l y and never relaxed. She had superior i n t e l l i g e n c e . The problem was seen as centered i n the mother-child r e l a t i o n s h i p — t h e lack of love together with the con t r o l of the c h i l d . Recommendations were made to focus s o c i a l work help on a i d i n g the mother to relax and express her f e e l i n g s , as well to help her gain an under-standing of the c h i l d ' s behaviour. Introspection on Mrs. A's part was to be kept to a minimum because of the upsetting experience Mrs. A had a f t e r K i t t y ' s b i r t h which the doctor had - 38 -described as "a near psychosis". WORKER'S ACTIVITY: A home v i s i t was made i n i t i a l l y and i t appears that a face to face contact may never have been effected at a l l , or c e r t a i n l y not u n t i l much l a t e r , i f the v i s i t had not been made. The worker immediately encouraged Mrs. A to t a l k about the s p e c i f i c problem and also about the source of r e f e r r a l . When she had done so, the worker gave an explanation of agency f u n c t i o n and also explained the need f o r parent's p a r t i c i p a t i o n i n the helping process. The worker accepted the mother's need to t a l k about the c h i l d , encouraged and accepted the f e e l i n g s that mother was able to b r i n g out about the b i r t h of the c h i l d and about her own p h y s i c a l con-d i t i o n . The worker recognized her f e e l i n g s by r e s t a t i n g i n d i f f e r e n t words what the c l i e n t had sa i d . The worker then r e l a t e d generally the theory of multi-causation of behaviour, but ended by s p e c i f i c a l l y saying that i t was d i f f i c u l t to t e l l how much the mother's condition a f f e c t e d the c h i l d . It i s d i f f i c u l t to t e l l from the recording whether the s p e c i f i c reference at t h i s point was h e l p f u l . It c e r t a i n l y was d i r e c t and could have been reassuring, because Mrs. A appeared to have some g u i l t about the f a c t that t h i s c h i l d was not planned f o r , and that Mrs. A's p h y s i c a l c o n d i t i o n was i n some way linked with K i t t y ' s nervousness. How conscious t h i s was on her part i s not known. It i s also p o s s i b l e that- some of the l a t e r resistance was added to by t h i s reference to Mrs. A's condition having a f f e c t e d the c h i l d . On the other hand, i t i s also p o s s i b l e that the early a t t e n t i o n given i n an accepting - .39 -way to a matter which gave considerable concern to the mother (and which l a t e r proved to be r e l a t e d to the core of the p r o b l -em) may have eventually helped the mother to accept the p o s s i b i l i t y that her a t t i t u d e toward the c h i l d was an import-ant f a c t o r i n the causation of the c h i l d ' s problem. At the time the mother responded by t a l k i n g about the c h i l d and her condition. The worker gave a d e t a i l e d account of the way i n which the agency c a r r i e d out i t s function. The record does not state, but the impression i s gained that the worker accepted the defensiveness of the mother which now took up a considerable part of the interview. The worker apparently accepted the mother's wish to stray from the matter being discussed to i r r e l e v a n t matters, and when mother returned to the subject of the problem, again her defensiveness was apparently accepted. The worker then focuses the disc u s s i o n on one aspect of the problem which has not yet come up i n the interview. There was fur t h e r focusing of di s c u s s i o n on an aspect of the c h i l d ' s problem which may also be thought of as an expression of d i r e c t i n t e r e s t i n the c h i l d and i n the parents. The worker then gave a d i r e c t expression of h i s desire to be h e l p f u l , and as-surance that future home v i s i t s would be made i f t h i s i s necessary. The worker i n i t i a t e d a telephone c a l l and gave assurance that the agency could give help with the s p e c i f i c presenting problem of the c h i l d , which i t may be noted, received a very p o s i t i v e response from the mother. r- 4 0 -The worker made a c o l l a t e r a l contact, interviewing the doctor who suggested the agency contact. Further telephone c a l l s were i n i t i a t e d and an appointment was made with Mother. The worker accepted the negative f e e l i n g she expressed about the c h i l d . The worker encouraged her to talk about her present and past family l i f e and gave c l a r i f i c a t i o n and support. The worker also generalized the mother's f e e l i n g s i n order to r e l i e v e g u i l t which the mother seemed to have. The various techniques formerly mentioned were repeated by the worker throughout the intake interviews with mother. WORKER'S ACTIVITY: with the father: The father was present i n the i n i t i a l home v i s i t but v i r t u a l l y took no part i n i t . In l a t e r contacts, the worker accepted the father's wish to t a l k about matters unrelated to the problem, but of i n t e r e s t to fa t h e r . The worker's keen perception of the f e e l i n g of pride that father was able to brin g out about his job and re l a t e d a c t i v i t i e s , gave the impression that these f e e l i n g s were recognized and accepted. Father began to discuss the problem and the worker accepted hi s defensiveness. The worker focused on some aspect of the problem not yet mentioned and used some c l a r i f i c a t i o n i n regard to the problem. This was accepted by father who elaborated on c e r t a i n events which seemed to him to bring about changes i n the c h i l d ' s behaviour. The worker encouraged father to t a l k about present and past family l i f e , and explained about the way i n which the agency c a r r i e s out i t s function. - 41 -APPARENT RESULT OE WORKER'S ACTIVITY: Mother decided to accept the agency's help and her atti t u d e changed to the point where the worker was able to record that she became "anxious to seek help". The record states that gradually mother c o n t r o l l e d the interviews l e s s and l e s s , and became more relaxed. The record reveals that she kept the focus of casework interviews on the c h i l d , but she involved h e r s e l f to the extent that she could see that changes i n her handling of the c h i l d brought some improvement i n the c h i l d ' s behaviour. The c h i l d ' s screaming had stopped before the completion of the intake study. K i t t y was s t i l l waking up about once during the night but would go back to sleep within a reasonable length of time. The record states that father became cooperative i n sharing more family a c t i v i t y , and he and mother began r e g u l a r l y enjoying outside r e c r e a t i o n together. The mother was able to accept the diagnostic con-ference recommendations: that she would be the focus of t r e a t -ment; she was also able to accept a t r a n s f e r to the s o c i a l worker i n the agency who i s responsible f o r continued service on cases where the intake study has been completed. This demonstrates a decrease i n resistance to an extent which i s h e l p f u l to parents, and to c h i l d . As a re s u l t of t h i s decrease i n resistance, mother was able to p a r t i c i p a t e i n interviews held weekly f o r nine months. K i t t y was then re-evaluated by the c l i n i c team as "much improved," "although s t i l l somewhat anxious". Six more interviews were held. The c l o s i n g notation on the case states?. - 42 -that: "Mother's emotional equilibrium has become s t a b i l i z e d . Within the l i m i t s imposed by the need to keep i n t r o s p e c t i o n to y a minimum, she understands the causes of the c h i l d ' s d i f f i c u -l t i e s and how to help her outgrow them. She has gained an understanding of h e r s e l f , i s o p t i m i s t i c about the future. The c h i l d i s now mingling with other c h i l d r e n and showing spontan-e i t y to some degree, according to the record summary. Her sleeping habits have improved considerably. "Goals achieved i n large measure." The "B" Case R e f e r r a l : The r e f e r r a l was made by the mother at the sugges-t i o n of the school nurse. CHILD: John B i s an eleven year o l d boy, the f o u r t h c h i l d i n a family of f i v e c h i l d r e n . The older s i b l i n g s are several years older than John. The presenting problem included several aspects of John's behaviour: nervousness, disobedience, poor schoolwork, annoying other c h i l d r e n , which created a d i s t u r b -ance i n the school. He was disobedient at home, and also had an enuresis problem. FAMILY: Mr. B i s 60 years o l d . He repairs e l e c t r i c a l equip-ment and makes a very modest, but adequate income. Mrs. B i s 43 years o l d . Neither parent takes part i n community a c t i v i t -i e s . They do some s o c i a l v i s i t i n g but t h i s does not occur very frequently. The m a r i t a l r e l a t i o n s h i p i s described i n the record as "not close". The worker stated that Mrs. B drew a - 43. -p a r a l l e l between her f a t h e r and her husband and the worker thought that Mrs. B saw her husband as a father f i g u r e . Mr. B worked a considerable amount of overtime and appeared to be di s t a n t with h i s wife, when he was at home. He never discussed f i n a n c i a l matters with her because she worried about them, and by t h i s and other comments, the impression i s gained that he sees h i s wife as someone to be taken care of, but not to be given r e s p o n s i b i l i t y or to share with him the making of any plans f o r the family. Mrs. B seemed to be s u f f e r i n g with s l i g h t depressions and some psycho-somatic complaints a s s o c i a t -ed with menopause. As a r e s u l t , the record states that she spent a good many evenings a week attending movies from which she derived some comfort. She d i d not take an i n t e r e s t i n the day by day incidents that were important to Johni. She said that she was happy when he was outside playing with other c h i l d r e n . TEAM FINDINGS: John was seen as a lonely depressed boy with strong resentment towards both h i s parents. He had high average p o t e n t i a l i n t e l l i g e n c e according to the assessment of the psychologist. However, he was unable to use h i s a b i l i t y to do good school work because of h i s anxiety about his h o s t i l i t y , and because he received minimal s a t i s f a c t i o n s from h i s r e l a t i o n " ships. Recommendation was made that John p a r t i c i p a t e i n play interviews with a male s o c i a l worker. I t was recognized by the c l i n i c team that Mrs. B could not give any more at t e n t i o n - 4 4 -or loving care to John unless she h e r s e l f was able to f i n d more happiness i n the family s i t u a t i o n . The frequency of contacts with the mother was l e f t to the worker's d i s c r e t i o n . I t was thought that Mr. B was les s troubled and that he could use c l i n i c services to a l i m i t e d extent to help him understand the behaviour of the boy, and e s p e c i a l l y to see the boy's need f o r companionship. The c l i n i c team saw the community as a h e l p f u l resource i n providing s u i t a b l e a c t i v i t i e s and companion-ship f o r a boy of t h i s age. This was emphasized because of the assessment that the parents would have a very l i m i t e d a b i l i t y to change. MOTHER: The worker described her as "emotionally f l a t " , and fur t h e r stated that she speaks of her husband and her c h i l d r e n " i n a detached way". As already mentioned, she s u f f e r s from s l i g h t depressions, and her own statements give the impression that she spends l i t t l e time with family members and has l i t t l e i n t e r e s t i n them. She i s apparently an adequate housekeeper and manager and i s r e l i a b l e i n ge t t i n g a l l the p r a c t i c a l day to day duties completed. Mother manifested resistance i n i t i a l l y by p a r t i c i p a t -ing very l i t t l e i n the interview and by her general apathy regarding the boy. She stated: " I f only the boy would come home with a good report card, everything would be a l r i g h t . " This seemed to imply that a good report card would s a t i s f y the school and mother would not be under pressure from the - 4-5 -school to contact the c l i n i c . She stated that she could not come f o r any o f f i c e interviews, because they were too incon-venient. This statement has some b a s i s i n r e a l i t y because of the distance of the home from the agency, and Mrs. B's depressed f e e l i n g s which apparently leave her without much energy. However, i t would have been possible f o r Mrs. B to come f o r some o f f i c e interviews had she been f e e l i n g w e l l . In subsequent interviews there was no change i n the way Mrs. B manifested resistance. The major defense mechanisms which Mrs. B seemed to be using were detachment or i s o l a t i o n , and turning her f e e l i n g s against h e r s e l f . She weeps a considerable amount i n the i n t e r -views, and has some s l i g h t depressions. She apparently uses den i a l when she implys that everything would be a l r i g h t i f John would only bring home a good report card, and at the same time, she may be p r o j e c t i n g some of the r e s p o n s i b i l i t y unto John. FATHER: Mr. B was a hard working man with r i g i d ideas and standards about how things should be done. He apparently l i k e d to keep busy and d i d not get close enough to people to share his emotions to a s i g n i f i c a n t degree, or to be a companion to anyone. He i s r e l i a b l e and honest, and i f he states that he w i l l carry out a plan, he can be r e l i e d upon to do so. His age was seen as s i g n i f i c a n t regarding h i s a b i l i t y to change. Mr. B manifested resistance i n the i n i t i a l interview by being considerably l a t e without g i v i n g any explanation f o r - 4 6 -i t . Although the function of the agency had been explained to him, he stated that he did not know why he had to be seen by the worker. He fu r t h e r stated that he had a happy home, did not f i g h t , smoke, or drink, and had s u c c e s s f u l l y - r a i s e d four c h i l d r e n . Later during the interview, he repeated these remarks. In subsequent interviews, he stated that he did not see why the boy had d i f f i c u l t i e s because he and h i s wife were happy. The major defense mechanism which the father seemed to be using was p r o j e c t i o n of his h o s t i l i t y unto the worker— he did not know why he had to be seen, implying that the r e s p o n s i b i l i t y was hot h i s . Later he seems to be p r o j e c t i n g the d i f f i c u l t y onto the boy, implying the boy had no r e a l reason to be di s p l a y i n g t h i s type of behaviour, or at l e a s t the d i f f i c u l t y did not have any thing to do with what he or Mrs. B were doing. WORKER'S ACTIVITY: with the mother: A home v i s i t was made i n i t i a l l y i n which Mrs. B's defensiveness was accepted by the worker. Negative f e e l i n g about the c h i l d as expressed by Mrs. B was also accepted by the worker. The funct i o n of the agency was explained and Mrs. B was encouraged to t a l k about the s p e c i f i c problem. Later the worker explained the need f o r parents' p a r t i c i p a t i o n i n the helping services given by the agency, and encouraged her to t a l k about h e r s e l f . Her wish to discuss matters unrelated to the problem or the family was accepted. - 4 7 -More home v i s i t s were made, i n which Mrs. B's fe e l i n g s were accepted, p a r t i c u l a r l y her need to weep. She was encouraged to ta l k about her present and past family l i f e . She was also given the assurance that home v i s i t s would be made i n the future i f t h i s proved to be more convenient f o r her. C o l l a t e r a l v i s i t s were made, p a r t i c u l a r l y to the teacher, p r i n c i p a l , and school nurse, i n which a good deal of explanation of the agency function was given as well as an i n d i c a t i o n of the i n t e r e s t the agency had i n helping John. WORKER'S ACTIVITY: with father: The worker used i d e n t i c a l techniques with father as he did with mother with the exception that s p e c i a l l y timed evening appointments were made. Father was also given the assurance that future appointments could be s p e c i a l l y timed f o r h i s convenience i f t h i s proved to be necessary. APPARENT RESULT OE WORKER'S ACTIVITY: The record i n d i c a t e s that Mr. and Mrs. B became involved i n the services to the extent that they were able to t a l k about the boy and about themselves at considerable length, and were, according to the worker, somewhat more relaxed. The teacher reported that the boy's a t t i t u d e had improved to some degree i n school, and mother confirmed that the boy's behaviour also improved at home. Considering the i n t e n s i t y of the problem, e s p e c i a l l y the l i m i t e d capacity of the parents f o r change, a s k i l l f u l job was performed i n order that r e s i s t -- 48 -ance was decreased to the extent that the "boy was able to ben e f i t from the services given by the agency. The parents were able to p a r t i c i p a t e i n the interview with the continued service worker who was now responsible f o r carrying out treatment recommendations. It should be added that Mr. and Mrs. B manifested resistance i n the same way and with apparently much the same i n t e n s i t y that was present i n the intake study. The parents stated they r e a l l y wanted to with-draw from the agency. The resistance was again decreased with techniques almost i d e n t i c a l to those used by the intake worker. As a r e s u l t , the boy has p a r t i c i p a t e d i n 36 play interviews. The worker, the teacher and p r i n c i p a l have agreed that the boy's attitude has improved considerably. John was getting b etter marks i n school; i n f a c t , his report card included some A's, which was considered a good performance. There i s no more of the annoyance of other youngsters which was so d i s t u r b i n g to the school as a whole. The enuresis which occurred n i g h t l y occurs about once weekly. The worker stated that the boy i s looking b e t t e r p h y s i c a l l y . The parents have been seen approximately once monthly. There appears to be no s i g n i f i c a n t change i n the way they care f o r t h e i r son; although t h e i r p a r t i c i p a t i o n i n interviews indicated a change i n a t t i t u d e towards John. This change, together with the play interviews have apparently enabled the boy to make the gains i n adjustment which have been mentioned. The record gives no i n d i c a t i o n that support of per s o n a l i t y strengths was given during the intake study. There - 49 -were c e r t a i n strengths there and whether the e f f e c t of support-ing them would have decreased or increased resistance i n t h i s case can only be speculated upon. The impression i s gained that the intake study was very s k i l l f u l l y handled. The people of importance i n the s i t u a t i o n were contacted and no attempt was made to c l a r i f y or i n t e r p r e t the boy's behaviour to them. Defensiveness was accepted, and persistence was evident i n the worker's continued use of home v i s i t s i n order to make many of the contacts. The "C" Case R e f e r r a l : R e f e r r a l was made by the mother at the suggestion of the school p r i n c i p a l and l a t e r , the doctor. CHILD: Joseph i s an eight year o l d boy, the eldest i n a family of four c h i l d r e n . The presenting problem indicates that he was creating a disturbance i n school: disobedience, swearing, masturbation with other boys. At home, he was b e l l i g e r e n t and un-cooperative. He teases younger s i b l i n g s but becomes almost h y s t e r i c a l when threatened with punishment by his parents. FAMILY: Mr. C i s a 30 year old engineer who makes a some-what be t t e r than average income. He belongs to several p r o f e s s i o n a l associations and attends meetings although he i s not able to p a r t i c i p a t e very a c t i v e l y because he i s out of town a good deal. He also belongs to a church group. Mrs. C i s 30 years old. She takes no active part i n organized - 50 -community a c t i v i t y . She attends church, v i s i t s f r i e n d s . She used to be very active i n sports before her marriage but does not p a r t i c i p a t e now. The record states that the m a r i t a l r e l a t i o n s h i p appears good. The parents say they f i n d s a t i s -f a c t i o n i n the marital r e l a t i o n s h i p . There are no s i g n i f i c a n t health problems. MOTHER: The mother stated that she was sp o i l e d as a c h i l d and treated l i k e a baby by her whole family. She said she f e l t she had to "show" her family she could manage when she got married. Her l a t e r comment made the worker state that mother saw h e r s e l f as being i n f e r i o r to her parents and s i b l i n g s , and that Mrs. C also saw the wife and mother roles as " r e s t r i c t i n g " . The w worker stated that t h i s c l i e n t attempted to overcome her i n f e r i o r i t y feelings'by s t r i v i n g to appear adequate, to prove she can do things w e l l . She sees h e r s e l f , according to her own statements, as having a higher s o c i a l status than her neigh-bours and she has high expectations f o r h e r s e l f , and f o r the boy, although the worker states that she i s unaware of these high expectations. The impression was gained that she was a t a l k a t i v e person, and was somewhat dominant i n the m a r i t a l r e l a t i o n s h i p . Mother manifested resistance i n the i n i t i a l interview by s t a t i n g that since her o r i g i n a l request f o r agency s e r v i c e , she had contacted the school p r i n c i p a l again. She had asked him i f she needed to contact the c l i n i c now because the boy seemed to be doing "okay" i n school. The p r i n c i p a l • a d v i s e d - 51 -contacting the c l i n i c . Mother then stated that she had con-tacted the family doctor to see i f he thought that c l i n i c contact was necessary. He advised the contact a l s o . She stated that she thought Joseph's d i f f i c u l t i e s were caused by h i s companions. In subsequent interviews, Mrs. C manifested r e s i s t -ance by missing an appointment, telephoning an hour l a t e r to see i f she could s t i l l come. An appointment was scheduled to take place the same afternoon, and Mrs. C a r r i v e d a h a l f hour l a t e because she had l o s t her car keys. By the end of the interview, she stated that she "couldn't make up her mind whether to come or not". She telephoned to cancel the next interview, but decided to come a f t e r t a l k i n g to the worker. She now stated that she thought she was i n some way respon-s i b l e f o r Joseph's problems. She s a i d she "wonders i f they are going to a l o t of trouble f o r nothing". The worker states that mother was somewhat depressed at the time and "indicated quite a b i t of resistance to continuing". The major defense mechanisms used by mother appear to be denial of the problem i n the beginning; l a t e r , she seems to project the reason f o r the d i f f i c u l t y onto the boy's f r i e n d s . When she begins to recognize p a r t i a l l y her own involvment i n the boy's d i f f i c u l t i e s , she seems to turn her f e e l i n g s against h e r s e l f ; she i s depressed and p e s s i m i s t i c about any good coming from the c l i n i c contact. FATHER: The mother stated that he i s agreeable and w i l l go a - 52 -long way to avoid an argument or quarrel. The f a t h e r s a i d that when he "gets mad, he blows up". The worker states that father appeared to be a passive person, who i s a very industrious worker. The worker gained the impression that much of father's ambition i n h i s work was stimulated by h i s wife's expectations of him. The worker states that Mr. C appears to be quite i n t e r e s t e d i n h i s c h i l d r e n , noting also, that he was very "agreeable" i n the interviews but "lacked spontaneity". Mr. C manifested resistance i n the i n i t i a l interview by s t a t i n g that he d i d not want the c l i n i c to "take over the problem," nor did he want to become "too involved" with the c l i n i c . He s a i d that he wanted " l i m i t e d help". His p a r t i c i p a t i o n without any degree of spontaneity i s also part of h i s resistance. In subsequent interviews, Mr. C manifested resistance by constantly minimizing the importance of the c h i l d ' s c o n t r o l of his f e e l i n g s or the c h i l d ' s defiance of the parents. The major defense mechanisms used by Mr. C appear to be denial of the seriousness of the problem and i s o l a t i o n of h i s f e e l i n g s . It appears that c h a r a c t e r i s t i c a l l y he does not become "too involved". TEAM FINDINGS: The c h i l d was found to be a c o n t r o l l e d , serious boy who t r i e s hard to cooperate but who f e e l s i n f e r i o r to the r e s t of h i s family. He has considerable h o s t i l i t y toward the mother and toward s i b l i n g s . He i s anxious f o r h i s own p h y s i c a l safety. - 5 3 -Recommendation was made f o r Joseph to p a r t i c i p a t e i n approx-imately four play interviews designed to help him release h i s anger and deal with h i s anxiety, and g u i l t f e e l i n g s . Joseph's d i f f i c u l t i e s were thought to be caused i n great measure by the mother's c o n t r o l of him, so that he could not become independ-ent, or assume r e s p o n s i b i l i t y i n any way. This, together with the mother's inconsistency i n d i s c i p l i n e made the boy f e e l that she d i d not love him. Recommendation was given that mother be made the focus of s o c i a l work help to help her f e e l that her rol e was more important both to the c h i l d and to the family. Other goals were seen as help f o r mother i n handling her fe e l i n g s so that she could relax and demand l e s s of the boy. Father was to be seen occas i o n a l l y , but since he i s away from the home a good deal, and d i d not want to become too involved,' i t was thought that only a l i m i t e d degree of p a r t i c i p a t i o n could be expected from him. WORKER'S ACTIVITY: with mother A home v i s i t was made i n i t i a l l y , and an explanation of agency function and an account of the agency's way of carrying out t h i s f u n c t i o n was given. Worker encouraged mother to t a l k about the s p e c i f i c problem, and the source of r e f e r r a l . The worker accepted negative f e e l i n g s about the c h i l d , and also accepted mother's defensiveness. The worker gave information about behaviour i n general s t a t i n g that some-times a f t e r an upset i n school things l i k e t h i s "blow over" and sometimes they do not, depending upon whether the upset - 54 -was caused by something i n the immediate s i t u a t i o n , or some-thing deeper. The worker accepted the mother's wish to t a l k about other parents i n the neighbourhood and accepted her f e e l i n g that these parents seem to do a l r i g h t with t h e i r c h i l d r e n even though they do not worry about them. The worker generalized the mother's f e e l i n g i n an attempt to r e l i e v e g u i l t . The worker gave reassurance that the agency could give service that would help with the s p e c i f i c problem, and encouraged mother to t a l k about the c h i l d . The worker l a t e r focused the disc u s s i o n about the boy to events i n his early years. A f t e r the mother had given a good deal of information about the boy, the worker c l a r i f i e d one aspect of h i s school behaviour f o r mother. The worker l a t e r expressed d i r e c t i n t e r e s t i n the mother and explained the need f o r parent's p a r t i c i p a t i o n i n the helping process. The worker encouraged mother to t a l k about h e r s e l f , and made s p e c i a l l y timed appointments which would be convenient f o r the mother. Encouragement was given to the parents to explain the c l i n i c contact to Joseph i n a p o s i t i v e way. There was repeated acceptance of t h e i r defens-iveness. WORKER'S ACTIVITY: with father The worker gave a d e t a i l e d account of the way i n which the agency c a r r i e s out i t s f u n c t i o n and expressed a desire to help the family. The worker then encouraged father to t a l k about the s p e c i f i c problem. A f t e r the father d i d so, the worker encouraged him to t a l k about past family l i f e and - 55 -accepted father's defensiveness. The worker encouraged father to t a l k about present family l i f e and c l a r i f i e d one aspect of the boy's behaviour. The worker f u r t h e r c l a r i f i e d the meaning of Joseph's overt defiance and i t s possible causes. The father responded by s t a t i n g some of Joseph's p o s i t i v e q u a l i t i e s and the worker supported these strengths. APPARENT RESULT OF THE WORKER'S ACTIVITY: Both parents p a r t i c i p a t e d to some degree i n i n t e r -views. The mother, i n p a r t i c u l a r , was able to p a r t i c i p a t e to the extent that she could recognize, f i n a l l y accept, her involvment i n creating Joseph's d i f f i c u l t y . In the fourth interview she even t r i e d to make the worker t e l l her how much of Joseph's d i f f i c u l t y she was cr e a t i n g . No change i n the behaviour of the c h i l d or i n the parents' attitude toward him i s recorded. Mr. and Mrs. C were able to accept the recommen-dations f o r Joseph to p a r t i c i p a t e i n a b r i e f s e r i e s of play interviews, and to accept t h e i r own need f o r f u r t h e r i n t e r -views, with the focus of work to be with Mrs. C . As a r e s u l t of the decrease of i n i t i a l r e sistance, the mother was able to p a r t i c i p a t e i n s i x interviews which con-s t i t u t e d a b r i e f treatment s i t u a t i o n . Joseph was seen i n four play interviews. The f a t h e r was seen twice. The case was closed prematurely as a r e s u l t of the family's plan to move to a community where the services of a c h i l d guidance c l i n i c were not a v a i l a b l e . The case was closed with a notation to that e f f e c t . Both the teacher and the f a t h e r commented on the boy's improved school progress. The mother had a good under-- 56 -standing of her own c o n t r i b u t i o n to i t . She stated that she s t i l l handles the boy at times i n a manner which she knows i s harmful and that something inside her does not l e t her do what she knows i s the r i g h t thing. She also indicated that she would be unable to change a great d e a l . The record states " l i m i t e d goals have been reached". The impression i s gained that the f i r s t three i n t e r -views with mother were very s k i l l f u l l y handled and that resistance was decreased considerably as a r e s u l t . The con-tinued demonstration of the worker's desire to be h e l p f u l , and h i s assurance that help could be given f o r the s p e c i f i c problem appeared to be e f f e c t i v e i n helping Mrs. C face the r e a l i t y of her own involvment i n the d i f f i c u l t y . The worker's acceptance of mother's defensiveness apparently helped her involve h e r s e l f to some extent i n the service offered by the agency. The recording of l a t e r interviews gives the impression that the worker did not always recognize the mother's f e e l i n g s . For example, when she defensively i n s i s t s that parents need more t r a i n i n g , s i m i l a r to that of p r o f e s s i o n a l people, the worker disagreed with her rather than exploring her f e e l i n g s on t h i s subject. The worker further stated that most parents handle s i t u a t i o n s s a t i s f a c t o r i l y . Depending upon the actual wording i n the interview and the worker's intent i n saying t h i s , i t could have been reassuring. As i t i s recorded, i t gives the impression that mother would be l e f t with the idea that she i s not doing as well as most parents are. This i s an idea\ which i s already c e n t r a l i n her p e r s o n a l i t y and her - 57 -f e e l i n g s of i n f e r i o r i t y could be e a s i l y strengthened. I t i s possible that t h i s a c t i v i t y on the part of the worker increased resistance. It was followed by the mother i n s i s t i n g that the worker t e l l her how much of the d i f f i c u l t y she was creating. She i s lowering a defense, but she appears to be handling i t i n a somewhat h o s t i l e manner. The worker s k i l l f u l l y states that she i s one important f a c t o r i n Joseph's d i f f i c u l t y . (Mother expressed h o s t i l i t y to the continued service worker about t h i s incident of the intake worker not t e l l i n g her enough and "sparing her f e e l i n g s " . ) It may be speculated that the increase of resistance during the intake study and the p o s s i b i l i t y of the intake worker's cre a t i o n of i t , was responsible f o r a c e r t a i n high degree of resistance throughout the mother's contact with the agency. On the other hand, i t i s p o s s i b l e that mother had progressed and involved h e r s e l f i n casework services according to her capacity. As a r e s u l t of decreased resistance on the part of the mother, the c h i l d did b e n e f i t to some degree from the services offered by the agency. The "D" Case R e f e r r a l : Referral was made by a doctor's l e t t e r . CHILD: Peter D i s a three year o l d boy, the eldest of two c h i l d r e n i n the family. The presenting problem i s described as: the boy's d a i l y fever; he i s i r r i t a b l e and demanding during the day, and wakes at night screaming and demands att e n t i o n from mother. He has poor eating habits, and a poor - 5 8 -appetite. FAMILY: Mr. D i s an accountant and makes a somewhat better than average income. He i s 32 years of age and i s taking night classes i n accounting. Mrs. D i s 30 years of age. Neither parent takes part i n any organized community a c t i v i t y . Both p a r t i c i p a t e i n some s o c i a l v i s i t i n g . The ma r i t a l r e l a t i o n -ship i s described by the parents as being e s s e n t i a l l y happy. Father states his d i s s a t i s f a c t i o n with Mrs. D as a mother, and mentions that she has become more i r r i t a b l e since t h e i r marriage. This, creates an impression that the m a r i t a l r e l a t i o n -ship has many negative elements i n i t . Regarding s i g n i f i c a n t health problems, the c h i l d was h o s p i t a l i z e d on f i v e d i f f e r e n t occasions f o r minor operations i n c l u d i n g tonsilectomy. The parents were not allowed to v i s i t Peter on these occasions since he became upset when they d i d v i s i t . MOTHER: The record states that the worker considered that mother was dominant i n the marriage and c o n t r o l l i n g i n her re l a t i o n s h i p s i n general. Mother d i d not mention any c r i t i c i s m of her husband and she a t t r i b u t e d her i r r i t a b i l i t y since the marriage to her d i f f i c u l t i e s with the c h i l d . The worker observed that mother pushed Peter away when the c h i l d t r i e d to be a f f e c t i o n a t e with her. The worker states that mother talked to Peter as though he were an adult, making many demands of him. Mother stated that she f e l t inadequate as a mother. - 59 -Mrs. D manifested resistance i n the i n i t i a l contact by telephone which the worker i n i t i a t e d . The mother ind i c a t e d "hesitancy"; she said that the doctor had suggested that she spank the c h i l d , and she d i d not know whether t h i s was responsible f o r some improvement i n the c h i l d ' s behaviour, or whether i t was because recently he was able to be outside more. In interviews l a t e r , the mother manifested resistance by saying "my friends would have a f i t i f they knew I was coming to the c l i n i c . " She indicated that her parents would have the same reaction i f they knew that she had contacted the c l i n i c . She stated the boy had been d i f f i c u l t since b i r t h and she kept the focus on the boy's behaviour during the intake study. (The record of work with the father a f t e r the intake study was completed a c t u a l l y reveals father's statement that Mrs. D d i d not know whether to continue coming to the c l i n i c during the intake study or not. There was apparently consider-able resistance on mother's part, which was not a l l o v e r t l y manifested.) The major defense mechanisms used by the mother when r e s i s t i n g casework se r v i c e s , appears to be denial of the seriousness of the problem, by avoidance of discussing, and t a l k i n g about s u p e r f i c i a l i t i e s ; she also projects a good deal of the d i f f i c u l t i e s unto the c h i l d . FATHER: The worker states that Mr. D controls h i s emotions and that h i s comments in d i c a t e that he i s ei t h e r unable to - 60 -express a f f e c t i o n , or expresses i t to an extremely l i m i t e d degree. Father said that he always stuttered u n t i l he was an adult when he took speech c o r r e c t i o n c l a s s e s , which correc-ted the speech d i f f i c u l t y f o r the most part. Father stated that he withdrew from most school a c t i v i t i e s , and s o c i a l groups and s t i l l does to some extent. The record gives the impression that father has rather high standards, i s not f l e x i b l e or spontaneous, but i n d i c a t e s such q u a l i t i e s as r e l i a b i l i t y , honesty, and frankness. Mr. D manifested resistance i n the i n i t i a l interview by being completely c o n t r o l l e d and showing no emotion. He t o l d the worker not to bother being diplomatic and he i n s i s t e d on being asked questions; there were long pauses i n the interview. In subsequent interviews, Mr. D manifested resistance by s t a t i n g that he saw the problem as being between h i s wife and Peter. Mr. D said that h i s wife d i d not handle the boy properly. Father cooperated s u p e r f i c i a l l y but d i d not involve himself i n the interviews. The major defense mechanisms which Mr. D appeared to be using i n t h i s manifestation of resistance were d e n i a l of any involvment on'his part i n the c h i l d ' s d i f f i c u l t y , and p r o j e c t i o n of the en t i r e r e s p o n s i b i l i t y unto h i s wife. The impression i s given that he i s o l a t e s h i s f e e l i n g s , and that he has developed c e r t a i n r e a c t i o n formations which conceal his anger, and r e s u l t i n r i g i d behaviour. TEAM FINDINGS: Peter was found to be i n the average range of - 61 -i n t e l l i g e n c e but was seen as an anxious, unhappy, over-contro-l l e d boy. He behaved as though he had too many l i m i t s set f o r him, a l l of which he accepted, rather than r e b e l l i n g against any of them. It was recognized that he needed release from anxiety i n a r e l a t i o n s h i p where he could be dependent. He was s l i g h t , f r a i l , and completely lacking i n aggression. The recommendation was made that s o c i a l work interviews be focused upon helping mother gain more status i n her r o l e as a mother, and relax her control over the boy. Father was to be seen oc c a s i o n a l l y i n order that, with support and encouragement, he might be enabled to give Mrs. D more recognition and help. WORKER'S ACTIVITY: with the mother The worker i n i t i a t e d a telephone c a l l and encouraged mother to t a l k about the s p e c i f i c problem. The worker accepted the mother and her uncertainty about how to deal with the problem. The worker encouraged mother to t a l k about t h e i r present family l i f e , g i v i n g assurance that the agency could give help with the s p e c i f i c problem. The worker generalized the mother's f e e l i n g i n order to r e l i e v e her g u i l t , supported her p e r s o n a l i t y strengths, and accepted her negative f e e l i n g s about the c h i l d and her own defensiveness. Information was given about behaviour i n general and c l a r i f i c a t i o n of Peter's behaviour i n p a r t i c u l a r . The worker encouraged the mother to explain the agency contact to the c h i l d i n a p o s i t i v e way, explaining the need f o r parent's p a r t i c i p a t i o n i n the services given by the c l i n i c Mother was encouraged to t a l k about past family l i f e . - 62 -WORKER'S ACTIVITY: with the father The worker accepted the father's defensiveness and explained the agency f u n c t i o n and way of carrying out t h i s function. The father was encouraged to t a l k about the s p e c i f i c problem and some information was given about the worker's o r i g i n a l i n i t i a t i o n of contact with the family of which the father d i d not seem to be aware. Father was also encouraged to t a l k about h i s present and past family l i f e and to t a l k about himself. The worker gave support of father's p e r s o n a l i t y strengths. APPARENT RESULT OF WORKER'S ACTIVITY: By the end of the intake study, although the c l i n i c team recommendations had s t i l l not been given, the mother stated that she had been t r y i n g to be more relaxed and lenient with the c h i l d , thus i n d i c a t i n g her r e c o g n i t i o n of where much of the d i f f i c u l t y was being created, and i n d i c a t i n g her in v o l v -ement i n the casework services being given. The father stated that the c h i l d was showing "marked improvement" i n eating and sleeping h a b i t s . The mother stated that she thought Peter's behaviour "was improved". Apparently, the i n i t i a l resistance was decreased to a s u f f i c i e n t extent that the noted improve-ment took place. It should be added that two interviews a f t e r the intake study was completed, the fa t h e r i n i t i a t e s the idea that he f e e l s he has a r e s p o n s i b i l i t y to help his wife when she i s f e e l i n g i r r i t a b l e , and added that previously, he had always f e l t that t h i s was unnecessary. As a r e s u l t , the family were able to accept t r a n s f e r - 63 -to another worker who continued g i v i n g treatment, and both parents p a r t i c i p a t e d i n interviews f o r nine months. Their actual m a r i t a l discord was f i n a l l y discussed and they accepted r e f e r r a l to a marriage counsellor, and cooperated with him i n a series of interviews. It should also be noted that on termina-t i o n of contact with the counsellor, i t was recorded that Peter's behaviour has shown a "steady and consistent improve-ment ". The impression i s gained that the intake study was very s k i l l f u l l y handled by the worker. There i s a question of how much resistance the mother was unable to express, and there i s a p o s s i b i l i t y that i f she had been able to express o v e r t l y more of her resistance, she might have been able to involve h e r s e l f to the degree that the m a r i t a l discord could have been discussed much sooner. The father was able to change to a considerable degree, i n sp i t e of h i s r i g i d ideas and a t t i t u d e s . Some c r i t i c i s m might be made of the worker's a c t i v i t y i n the i n i t i a l interview with father. The worker stops the flow of negative f e e l i n g that Mr. D i s expressing about h i s wife as a mother, g i v i n g information about the possible causes of behaviour, rather than recognizing and accepting Mr. D's f e e l i n g s . The "E" Case R e f e r r a l : R e f e r r a l was made by the mother at the suggestion of a s o c i a l worker who met the mother s o c i a l l y . CHILD: Helen i s a three and a h a l f year o l d g i r l , the - 64 -eldest of three c h i l d r e n . The presenting problem was given as "regression i n t o i l e t t r a i n i n g " ( s o i l i n g and smearing), acting "spoiled" ( s i b l i n g r i v a l r y , b i t i n g brother, some destructive behaviour i n the home). FAMILY: Mr. E i s a 27 year old man who manages a small business and makes a b e t t e r than average income. Mrs. E i s 28 years old. Neither take part i n any community a c t i v i t y but they enjoy l i s t e n i n g to c l a s s i c a l music together and frequent the art g a l l e r y . The m a r i t a l bond seems to have considerable a f f e c t i o n i n i t , according to the record. The record i n d i c a t e s , a l s o , that mother expressed some i r r i t a t i o n about father's shyness, and that Mr. E expressed some annoyance about h i s wife not being a capable mother and housekeeper. There were no s i g n i f i c a n t p hysical health problems. The degree of the mother's emotional upset w i l l be discussed l a t e r . MOTHER: Mrs. E was a dramatic, t a l k a t i v e , inconsistent person. She appeared to be fond of her husband. She seemed to be fond of her c h i l d r e n , u n t i l they reached the age of some independ-ence, when she became incapable of meeting t h e i r need f o r a f f e c t i o n , attention, and consistent l i m i t s . Her statement that she i s always hoping her own mother w i l l change and be kind to her, and other s i m i l a r comments, led the worker to record that Mrs. E seems to be searching f o r a good mother f i g u r e . She wanted a large family and wanted to "do the r i g h t thing by the c h i l d r e n i n t h e i r e a r l y years". Mrs. E manifested resistance to involving h e r s e l f i n casework interviews by c a n c e l l i n g the f i r s t interview, and - 65 -l a t e r bringing i n i n i t i a l l y an almost overwhelming amount of information. She stated that she d i d not have any serious problems, but immediately questioned the worker about whether or not her handling o f " s p e c i f i c incidents with the c h i l d r e n was c o r r e c t . At the end of the i n i t i a l interview, she s a i d "maybe a l l my problems w i l l be solved". Mrs. E manifested resistance i n subsequent contacts by c a n c e l l a t i o n of appointments, missing appointments without advising the worker beforehand; by her repeated questioning about whether she was handling her c h i l d r e n c o r r e c t l y , although she gave very l i t t l e information about how she a c t u a l l y managed them. When r e f e r r a l to a p s y c h i a t r i s t was suggested as perhaps being more what mother was wanting, she stated: "I'm not ready f o r that yet." The mother l a t e r suggested that maybe a l l her problems would be over by Easter. The major defense mechanisms used by mother appear to be a denial of her problems on the one hand, with dramatic emphasis upon them on the other. Mother's perception of r e a l i t y a c t u a l l y seemed to be so d i s t o r t e d and changing, that i t was thought that she had a serious ego-defect. FATHER: Mr. E was a quiet, shy man who was never very t a l k a t i v e or very a c t i v e . He made remarks which seemed to indicate that he was fond of his wife and of a l l the c h i l d r e n except Helen. He stated that he d i d not understand Helen's behaviour. He states that he sometimes loses his temper and - 66 -s t r i k e s the ch i l d r e n . He says that he longs f o r peace and quiet when he comes home, but never gets i t . He i s a steady worker, providing c o n s i s t e n t l y f o r h i s family. Mr. E manifested resistance i n i t i a l l y by avoiding the actual arrangement of a s p e c i f i c appointment. In the i n t e r -view, he stated that he f e l t Helen's problems were due to the handling Mrs. E and he were givi n g her. At one point he c r i t i c i z e d h i s wife f o r being a poor mother but he took some r e s p o n s i b i l i t y f o r Helen's behaviour. He took no i n i t i a t i v e f o r any a c t i o n to seek help at any point during the contact, although he p a r t i c i p a t e d i n four interviews. There was no resistance per se nor was there any r e a l involvement i n case-work ser v i c e s . The record does not give any i n d i c a t i o n of the use of any s p e c i f i c defense mechanism. TEAM FINDINGS: Helen was seen as a highly d i s t r a c t a b l e c h i l d who d i d not complete enough t e s t items to be accurately assessed by the psychologist. What Helen was able to complete placed her i n the slow normal range of i n t e l l i g e n c e . The c h i l d was hyper-active and appeared to s u f f e r from extreme dep r i v a t i o n of a f f e c t i o n a l needs, to the point where she was becoming a u t i s t i c . Kindergarten was recommended f o r her. The mother's disturbance was seen as the key problem and long range psychotherapy by a private p s y c h i a t r i s t was recommended f o r her. Casework services were to be offered around the handling of the c h i l d r e n , provided that these services were recognized by the p s y c h i a t r i s t as - 67 -being h e l p f u l to Mrs. E. WORKER'S ACTIVITY: with the mother The worker encouraged the mother to ta l k about the s p e c i f i c problem. The worker then explained the agency's way of carrying out i t s fun c t i o n , f u r t h e r explaining the need f o r parent's p a r t i c i p a t i o n i n the helping services offered by the agency. The worker accepted the mother's wish to t a l k about her past family l i f e and the impression i s gained that the worker encouraged t h i s by demonstrating i n t e r e s t i n what the mother wishes to say. The negative f e e l i n g which mother brings out about her past l i f e was accepted and assurance given that help can be provided f o r the s p e c i f i c problem. The worker i n i t i a t e s many telephone c a l l s i n which Mrs. E's defensiveness was accepted and the worker's d i r e c t expression of the desire to be h e l p f u l was given. R e f e r r a l was suggested as a means of mother meeting and handling her d i f f i c u l t i e s more e f f i c i e n t l y and support of pe r s o n a l i t y strengths was given. The worker made home v i s i t s i n which discussion was focused upon some aspect of the problem which was not previously mentioned. The mother was encouraged to t a l k about herself, and her fe e l i n g s were generalized i n order to r e l i e v e g u i l t . C l a r i f i c a t i o n was given regarding the s o c i a l h i s t o r y material, and information was given. The worker assured mother of the c o n f i d e n t i a l i t y of the interviews. The worker accepted d i r e c t h o s t i l i t y about the services given by the agency. WORKER'S ACTIVITY: with the father The worker i n i t i a t e d telephone c a l l s , and gave a - 68 -s p e c i a l l y timed appointment, explained the agency fun c t i o n and focused the discussion on the two major areas of mother's concern; her d i f f i c u l t y with Helen and her d i f f i c u l t y with the maternal grandmother. The father was encouraged to t a l k about what he saw as the important problem. The worker accepted father's ideas and restated the father's f e e l i n g that he and his wife were responsible f o r c r e a t i n g Helen's d i f f i c u l t y . A suggestion was given which i s designed to help c l i e n t handle an aspect of the problem more e f f i c i e n t l y , and general information about behaviour was provided. The worker accepted the father's negative f e e l i n g about Mrs. E. The worker encouraged father to t a l k about present family l i f e . The worker gave assurance that help could be given f o r the c h i l d ' s presenting problem, although t h i s might include r e f e r r a l to another agency. Father's negative f e e l i n g about Helen was accepted. C l a r i f i c a t i o n regarding c e r t a i n aspects of the c h i l d ' s behaviour was given. The worker accepted the father's negative f e e l i n g regarding a past experience on a job. Further explanation of the way i n which the agency/ c a r r i e s out i t s f u n c t i o n was provided. APPARENT RESULT OF V/ORKER'S ACTIVITY: The mother's resistance was decreased to the extent that a f u l l diagnostic study could be completed. H e l p f u l recommendations were made regarding the c h i l d , and r e f e r r a l of the mother to a p s y c h i a t r i s t was recommended. Mrs. E was able to accept t h i s recommendation,,consulted a p s y c h i a t r i s t , and p a r t i c i p a t e d i n several interviews with him. Unfortunately she - 69 -l a t e r discontinued interviews with the p s y c h i a t r i s t . As a result,' the c h i l d was evidently not helped. The c l i n i c d i d in d i c a t e i n the most h e l p f u l way p o s s i b l e what course of ac t i o n would help the family and the c h i l d . The persistence of the intake worker's contact would imply to the parents the concern of the worker f o r the c h i l d and the family. Real movement was indicated when Mrs. E who formerly r e s i s t e d the idea of seeking help from a p s y c h i a t r i s t c a r r i e d out her stated i n t e n t i o n of seeking p s y c h i a t r i c help.. The impression i s gained from reading t h i s record that t h i s case i s close to being one which a family or c h i l d r e n s 1 agency would carry to protect the c h i l d r e n . For t h i s reason, a follow-up v i s i t might have proved h e l p f u l i n deciding whether r e f e r r a l should have been made to another agency. The""F" Case R e f e r r a l : R e f e r r a l i s made by the mother with considerable pressure to do so from the school teacher, and school p r i n c i p a l . CHILD: Paul i s an eleven year old boy, the only c h i l d i n the family. The presenting problem i s h i s school behaviour; he i s repeating grade f i v e , and becomes almost h y s t e r i c a l at times, saying that everyone i s against him. FAMILY: Mr. F i s a truck d r i v e r , aged 44 years who makes a marginal but well managed income. Mrs. F i s 32 years of age. Neither parent takes part i n any organized community a c t i v i t y , - 7 0 -nor do they share any regular r e c r e a t i o n . The record states that the m a r i t a l r e l a t i o n s h i p appears s a t i s f a c t o r y and f a i r l y a f f e c t i o n a t e . MOTHER: The worker describes her as a c o n t r o l l i n g , excitable t a l k a t i v e woman with mood swings. The mother indicates her anxiety by such comments as "I just keep control of myself by a thread." The mother states she has a good r e l a t i o n s h i p with Mr. F. Mrs. F indicates her conscious hatred of her mother and deep a f f e c t i o n f o r her father. Mrs. F further makes i t c l e a r that she d i s l i k e s the role of mother. "I resented the baby (Paul) and didn't want any more." A f t e r a one month waiting period, the mother stated i n the i n i t i a l contact that the boy f e l t b e tter about school now and they did not need the help of the c l i n i c . The mother manifested resistance i n subsequent contacts through c a n c e l l a t i o n of an appointment, missing an appointment without mentioning i t to the worker beforehand, and c o n t r o l l i n g the interview by her talkativeness and i n a b i l i t y to focus on the c h i l d ' s problems. She did state that "the school makes the c h i l d d i f f i c u l t " . The major defense mechanisms used by the mother i n r e s i s t i n g casework services appear to be denial of the problem, and l a t e r , p r o j e c t i o n unto the school the responsib-i l i t y f o r creating the problem. FATHER: The worker describes father as being a steady worker, with a good sense of humour, easy going and i n c l i n e d to be - 71 -somewhat passive. Mr. F i s seen as having l i t t l e or no imagination. The worker states that he i s i n c l i n e d to com-promise rather than run the r i s k of i n c u r r i n g h o s t i l i t y . He speaks i n a p o s i t i v e manner about h i s wife and son. Mr. F demonstrated an unwillingness to t a l k about h i s r e l a t i o n s h i p with h i s wife or family, thus manifesting resistance to any great degree of involvement i n the casework services offered by the agency. In l a t e r interviews, father indicated that there was "not much wrong with the boy". He a t t r i b u t e d any d i f f i c u l t i e s Paul had to Mrs. F's habit of y e l l i n g at him. He sa i d that h i s wife was nervous and i r r i t a b l e because of the presence of her mother i n the home. The maternal grandmother i s apparently s e n i l e and i s a r e a l i s t i c source of trouble i n the home. The major defense mechanisms which Mr. F appeared to be using was denial of the seriousness of the problem, and a p r o j e c t i o n of the d i f f i c u l t y unto h i s wife. TEAM FINDINGS: The c h i l d was found to be an anxious boy with extreme h o s t i l i t y to h i s mother, and an unsatisfactors'- i d e n t i f i c a t i o n with his father. He i s i n the average range of general i n t e l l i g e n c e . Paul r e l a t e s s u p e r f i c i a l l y , i s i n h i b i t e d , and does not have a f i r m g r i p on r e a l i t y . Play interviews with a male s o c i a l worker were recommended to help Paul deal with h i s anxiety and h o s t i l i t y and to form a better i d e n t i f i c a t i o n with the male sex. Further recommendations were made f o r casework interviews to support mother's tenuous emotional - 72 -adjustment keeping i n mind that goals would be l i m i t e d because of the b r i t t l e n e s s of mother's defenses. Father i s to be encouraged to take a more active r o l e i n gi v i n g emotional support to h i s family. WORKER'S ACTIVITY: with the mother The worker encouraged the mother to t a l k about the s p e c i f i c problem and accepted her defensiveness. A desire to be h e l p f u l was d i r e c t l y expressed. The worker accepted the mother's h o s t i l i t y toward the school. The worker l a t e r supported mother's p e r s o n a l i t y strengths. Telephone c a l l s were i n i t i a t e d by the worker. Negative f e e l i n g regarding Paul was expressed by mother and accepted by the worker. The worker contacted the r e f e r r i n g teacher and p r i n c i p a l . The worker expressed d i r e c t i n t e r e s t i n the mother, accepting her h o s t i l i t y toward the school and h o s p i t a l nurses, and encouraging her to explain agency contact to the c h i l d i n a p o s i t i v e way. The worker focused the discussion to some aspect of the problem which had not been discussed formerly. The worker gave a suggestion designed to help mother handle some aspect of the problem more e f f i c i e n t l y , and accepted the mother's d i r e c t h o s t i l i t y . WORKER'S ACTIVITY: with f a t h e r A home v i s i t was made and an explanation of agency function given, as w e l l as a further explanation of the need f o r parent's to p a r t i c i p a t e i n the helping services offered by the agency. Father's negative f e e l i n g about Paul was - 73 -accepted and he was encouraged to t a l k about h i s present and past family l i f e . The worker accepted father's defensiveness and h i s wish to t a l k about himself, apparently encouraged him to do so. APPARENT RESULT OF WORKER'S ACTIVITY The parents were able to p a r t i c i p a t e to the extent that a complete diagnostic study could be made. Mother's resistance was decreased to the extent that she stopped pro-j e c t i n g the d i f f i c u l t y unto the school and stated: "We know we are to blame." Mother indicated great r e l i e f at being able to discuss the problem with someone. At the completion of the intake study, mother ind i c a t e d that Paul was entering into a c t i v i t i e s at school, that the teacher was taking a d i f f e r e n t a t t i t u d e toward him, and that he no longer hates the teacher. The school confirmed the f a c t that Paul's behaviour was generally improved. Mother stated that the boy's behaviour had improved at home and that t h i s eased the s i t u a t i o n f o r her. She s a i d : "You know I re j e c t e d him f o r years and years and now I have to gain h i s confidence." I t should be added that mother stated that while she was now patient with Paul, Mr. F was becoming impatient with him. It seems evident that the mother's resistance was decreased to the extent that both she and the boy were able to benefi t from the treatment implica-t i o n s of the intake study. As a r e s u l t of the decrease i n resistance, the mother was able to accept the diagnostic conference recommendations, - 74 -although she manifested increased resistance at t h i s time. C l i n i c contact was maintained f o r one year with regular play interviews f o r Paul and occasional contacts with mother. The case was closed with t h i s notation: "The c h i l d seems well enough to function without f u r t h e r help from the c l i n i c . He i s free of upsetting f e e l i n g s about himself and can apply himself to his schoolwork. The school finds that he i s p a r t i c i p a t i n g i n several group a c t i v i t i e s and demonstrates improved s o c i a l r e l a t i o n s h i p s as well as improved academic behaviour. The home s i t u a t i o n i s s t i l l not s a t i s f a c t o r y , but the boy i s better able to cope with i t . E f f o r t s to see the father d i d not meet with success." C r i t i c i s m of an otherwise s k i l l f u l job, may be made i n the lack of attention given to the fa c t that f a t h e r was 1 growing more i r r i t a b l e as mother was growing bet t e r . During the treatment period, no home v i s i t s were made i n order to draw the father into r e a l p a r t i c i p a t i o n i n interviews. Chapter three w i l l draw together common elements or trends apparent i n the an a l y s i s . Bergum, Mildred, The Father Gets Worse, A C h i l d Guidance  Problem, American Journal of Orthopsychiatry, Vol. 12, July 1942, p. 474. This a r t i c l e i n d i c a t e s the importance of e n l i s t i n g the father's p a r t i c i p a t i o n i n treatment, and describes what happens i n a number of cases, i f the father i s not interviewed. CHAPTER I I I SKILLS AND TECHNIQUES EOR  DECREASING RESISTANCE An analysis of the s i x cases was given i n Chapter Two. A synthesis of the common elements present w i l l be given, with reference to the resistance manifested and the worker's a c t i v i t y i n decreasing i t . In a l l the s i x cases presented, there was d e n i a l of the seriousness of the c h i l d ' s d i f f i c u l t y and of the parents' need f o r the services of the c l i n i c , although the parents had made the i n i t i a l request f o r help from the agency. In each case, there was a person of some au t h o r i t y i n the parents' s i t u a t i o n who suggested the r e f e r r a l ; the parents were.under some pressure to make the c l i n i c contact. Having made the i n i t i a l request f o r s e r v i c e , the parents were now reluctant to continue the contact with the c l i n i c . Everyone of these parents would apparently have withdrawn from the agency i f the s o c i a l worker had terminated the contact a f t e r t h e i r desire to withdraw had been expressed. In a l l cases, except Case "E", there was p r o j e c t i o n of the causes of the c h i l d ' s d i f f i c u l t y upon someone else i n the s i t u a t i o n . The d e n i a l of the seriousness of the problem, and of the existence of i t i n some instances, together with the p r o j e c t i o n of the causes of the d i f f i c u l t y upon someone - 7 6 -else,.seems to indicate a lack of ego-strengths i n the parents^ In Case "E", although there was no evidence of the defense of pr o j e c t i o n , the r e f e r r a l of the mother to a p s y c h i a t r i s t indicates the extent of the mother's psychological disturbance. The worker's a c t i v i t y i n every case was characterized by these features: acceptance of defensiveness, encouragement to t a l k about the s p e c i f i c problem, explanation of agency .' function, explanation of the need f o r parents' p a r t i c i p a t i o n i n the helping process, and encouragement to t a l k about present family l i f e . The worker's a c t i v i t y i n f i v e of the s i x cases included the following features: acceptance of negative f e e l -ing about the c h i l d , the use of home v i s i t s , and encouragement to t a l k about past family l i f e . In four of the s i x cases, the following features were i d e n t i f i e d : encouragement to t a l k about s e l f , encouragement to t a l k about i n t e r e s t s not re l a t e d to the presenting problem, i f the c l i e n t wished to do so, assurance that future home v i s i t s would be made i f t h i s became necessary to continued contact, assurance that agency s t a f f could give services to help with the presenting problem, support of p e r s o n a l i t y strengths, and gen e r a l i z a t i o n of expressed f e e l i n g s i n order to r e l i e v e g u i l t . "^It i s recognized that denial and p r o j e c t i o n are used i n varying circumstances by a l l i n d i v i d u a l s , and that t h e i r use does not ne c e s s a r i l y i n d i c a t e weak ego-strengths. In the cases studied, t h e i r use together with a wavering desire to seek help i n the face of r e a l d i f f i c u l t y suggested weak ego-strengths. - 77 -The following features were present i n three of the s i x cases: acceptance of verbalized emotions, recognition of emotions expressed by r e - s t a t i n g them i n a way which indicated acceptance of them, g i v i n g a d e t a i l e d explanation of the way i n which the agency c a r r i e s out i t s function, explanation of need f o r parents to i n t e r p r e t the agency contact to the c h i l d i n a p o s i t i v e way, s p e c i a l l y timed appointments, i n i t i a t i o n of telephone c a l l s , v e r b a l i z e d expression of worker's desire to help, c o l l a t e r a l v i s i t s , focusing the discussion on some aspect of the discussion not yet touched upon, g i v i n g informa-t i o n about behaviour, and c l a r i f i c a t i o n . In two of the s i x cases the following features were i d e n t i f i e d : acceptance of negative f e e l i n g s other than regarding the c h i l d , encouragement to t a l k about the source of r e f e r r a l , assurance that future appointments would be s p e c i a l l y timed i f t h i s were necessary to continued contact, and suggestions designed to help the c l i e n t handle some aspect of his s i t u a t i o n more e f f i c i e n t l y . In one of the s i x cases, assurance of the confiden-t i a l i t y of the interviews was given. These i d e n t i f i e d features were tabulated and the r e s u l t i n g schedule i s given on page 82". -The a c t i v i t y of the worker i n Case "A" was character-i z e d by the use of 2 3 of the 3 1 features i d e n t i f i e d i n a l l the cases. Case "C" was characterized by 2 2 of the t o t a l features. Cases "E" and "F" had 1 9 of the t o t a l features present. Case "D" had 16 features present, and Case "B" had 14 of the - 78 -i d e n t i f i e d features present. Table I on page gives these s t a t i s t i c a l r e s u l t s . Table II gives the same r e s u l t s i n summary" form. Trends: It may be noted that r e p e t i t i o n of a feature was not recorded. For example, although support of p e r s o n a l i t y streng-ths occurred i n four cases, and c l a r i f i c a t i o n occurred i n three cases, these features d i d not appear frequently i n the cases. Features such as acceptance, of defensiveness, explanation of agency function, and need f o r parent's p a r t i c i -pation were repeated a number of times. There also appeared to be a continual reaching out to the c l i e n t by the expres-s i o n of i n t e r e s t and desire to help; through the use of home v i s i t s , s p e c i a l l y timed appointments, the i n i t i a t i o n of telephone c a l l s , and the acceptance of whatever f e e l i n g s the c l i e n t was able to express, or whatever subject the c l i e n t was able to t a l k about. There was no a c t i v i t y i n i t i a t e d by the worker which would give i n s i g h t to the parents about t h e i r d i f f i c u l t y i n t h e i r r e l a t i o n s h i p s to each other or to t h e i r c h i l d r e n . No mention was made of the resistance, nor was there any attempt to i n t e r p r e t the reasons f o r i t . The resistance was marked and occurred at the time of i n i t i a l contact i n every case, and the worker i n each case was aware of the early and marked resistance. v The worker's consistent o f f e r of help and sustained - 79 -acceptance of the parents' responses, apparently provided a safe opportunity f o r the parents to externalize or bri n g into the open t h e i r resistance to the degree that they could begin to involve themselves i n the helping process and experience a change i n t h e i r f e e l i n g s about the s i t u a t i o n . In f i v e of the si x cases there was evidence of improvement i n the c h i l d ' s adjustment upon completion of the intake study. Five of the si x cases were su c c e s s f u l l y t r a n s f e r r e d to the continued 1 service worker f o r treatment from which the c h i l d u l t i m a t e l y benefited. In Case "E" where the mother was r e f e r r e d to a p s y c h i a t r i s t but l a t e r withdrew from the p s y c h i a t r i c i n t e r - ' views and from the treatment at the c l i n i c , there i s no evidence that the c h i l d benefited from the help. The case d i d show movement i n that there appeared to be a successful r e f e r r a l to the p s y c h i a t r i s t because the mother d i d have several p s y c h i a t r i c interviews. When the mother discontinued contact with the c l i n i c , she d i d state that she was handling the home s i t u a t i o n i n a more s a t i s f a c t o r y manner, but no de t a i l e d account of what she meant by t h i s statement i s recorded. Therefore, the mother may be returning to her use of the mechanism of d e n i a l , or she may have been helped, as she stated. "^One s i g n i f i c a n t f a c t o r i n the successful t r a n s f e r of these cases may be the fact that there was no waiting period between the intake study and treatment period as i s u s u a l l y the case. This f a c t o r i s discussed i n the Ward Laidman Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1957• Premature Withdrawal from Treatment  i n a C h i l d Guidance Agency. - 80 -In every case the diagnostic assessment led-the c l i n i c team to make treatment goals which were l i m i t e d . The word " l i m i t e d " was a c t u a l l y used i n des c r i b i n g the treatment goals i n four cases. In cases "D" and "E", although the word l i m i t e d i s not used, the d e s c r i p t i o n of plans f o r treatment implies that l i m i t e d goals were viewed as being of r e a l i s t i c help to the parents. In every case, the father was interviewed several times and he was encouraged to p a r t i c i p a t e i n the helping process. C o l l a t e r a l contacts were made i n every case. Chapter Four w i l l give the l i m i t a t i o n s of the findings and the implications of the study. 81 -Identified Features of the Worker's Activity Apparently Effeotive in Decreasing Resistance.1 I ACCEPTANCE« 1. Of defensiveness# 2. Of negative feelings regarding the child 3. Of negative feeling re other than child 4. Of direct hostility 5. Of other emotions expressed 6. Recognition of feelings expressed by restating them II ENCOURAGEMENT TO TALK: 1. About specific problem 2. About source of referral 3. About seL# 4. About past family life# « 5. About present family life*? 6. Interests not related to the probl III GIVING INFORMATIONi 1. About agency function 2, About agenoy's way of carrying out funotion 3* Need for parents' participation in the helping process 4. Need for interpreting to ohild about olinio contact in positive way 5. About behaviour IV EXPRESSION OF INTEREST 1. Home visits 2. Assurance that future home visits will be made i f necessary 3. Speoially timed appointments 4. Assurance that future appointments will be speoially timed 5* Initiation of telephone calls 6* Giving suggestions designed to help client handle some aspect of the situation more efficiently 7. Verbal expression of desire to help 8. Aseuranoe that agency staff can give help with the presenting problem 9* Collateral visits* V SUPPORT OF PERSONALITY STRENGTHS VI CLARIFICATION (Re-stating what olient has said so that a new connection is made between parts of the problem) VII FOCUSING the discussion to some aspect not previously disoussed VIII GENERALIZATION OF EXPRESSED FEELINGS in order to relieve guilt IX ASSURANCE OP CONFIDENTIALITY • It is reoognized that the features identified overlap to some degree. The impression was obtained that these features were part of the worker's activity to help the client participate more comfortably in the interview, rather than just for sooial history purpose. These features were not always specifically recorded, but their use was implied. - 82 -TABLE I Identified Features t ACCEPTANCEi Case A Case B 3ase C Case D Case E Case F Of defensiveness X X X X X X Df negative feelings re child X X X X X Df negative feeling - other X X Df direct hostility X X Df other emotions expressed X X X Df emotions by restating j X X X ENCOURAGEMENT TO TALK: about speoifio problem X X X X X X ftbout source of referral X X About self X X X X Fast family l i f e X X X X X Present family l i f e X X X X X X Interests not related X X X X J I V I N G INFORMATION* About agenoy function X X X X X X fey of carrying out funotion X X X Weed for parents1 participation X X X X X X Need for interpretation to child X X X About behaviour X X X EXPRESSION OP INTEREST Home visits X X X X X kssuranoe of future home visits X X X X Specially timed appointments X X - X Assurance that future appts. X X Initiation of telephone oalls X X X [Jiving suggestions X X Verbal desire to help X X X Assurance agenoy can help X X X X Collateral visits X X X SUPPORT OP PERSONALITY STRENGTHS X X X X CLARIFICATION X X X T FOCUSING X X X GENERALIZATION OP FEELINGS x X X X ASSURANCE OF CONFIDENTIALITY X TOTAL 23 14 22 16 19 19 - 83 -TABLE II I d e n t i f i e d Features i n Summary ACCEPTANCE 4 2 3 4 4 4 ENCOURAGEMENT TO TALK 5 6 3 4 4 GIVING INFORMATION 4 2 5 4 3 3 EXPRESSION OF INTEREST 6 5 5 2 6 4 SUPPORT OF PERSONALITY STRENGTHS 1 1 1 1 CLARIFICATION • 1 1 1 FOCUSING • 1 1 1 GENERALIZATION 1 l 1 1 ASSURANCE OF CONFIDENTIALITY 1 H ,_ >3 14 22 16 19 19 CHAPTER IV THE FINDINGS AND THEIR IMPLICATIONS The study was undertaken with a p a r t i c u l a r question i n mind: How do you help parents use the service they say they do not want, hut o r i g i n a l l y requested? How, i n other words, do you motivate a c l i e n t to use help? The s e l e c t i o n of cases which were i n d i r e c t l y " a u t h o r i t a t i v e l y " r e f e r r e d to the c l i n i c , highlighted the parental c o n f l i c t about accepting or refusing help, and demonstrated a group of c l i e n t s who presented marked r e s i s t -ance to casework ser v i c e s . While the C h i l d Guidance C l i n i c keeps no s t a t i s t i c a l record of the cases which are."authori-t a t i v e l y " r e f e r r e d and t h e i r ultimate d i s p o s i t i o n , the •impression was gained that almost h a l f of the cases r e f e r r e d i n t h i s way, withdrew before the intake conference, and at l e a s t h a l f of the remaining number withdrew a f t e r the completion of the intake study. It appears evident that, of the group of c l i e n t s who are r e f e r r e d to the agency "authori-t a t i v e l y , " many w i l l present marked resistance to casework services. This presents a serious challenge to the c l i n i c s t a f f and to the s o c i a l workers i n p a r t i c u l a r . The cases analysed i n the study presented a group of c l i e n t s with weak ego-strengths, a wavering desire to seek help, a l i m i t e d capacity to see the cause and e f f e c t r e l a t i o n -ship i n t h e i r d i f f i c u l t i e s , and a l i m i t e d capacity to form - 85 -strong r e l a t i o n s h i p s and use help. This supports an o r i g i n a l assumption, that the majority of cases r e f e r r e d i n t h i s way would be parents with weakened egos. It follows that they would need more help to involve themselves i n treatment. Perhaps an acknowledgement of these f a c t o r s at the intake conference would lead to a sound d e c i s i o n as to whether or not i t i s within the scope of the agency to o f f e r s e r v i c e s , and i f i t i s , to provide these services i n ways which w i l l decrease the i n i t i a l resistance of parents to the degree that they can involve themselves i n the helping process and benefi t from i t . The cases studied proved to be a group i n which the successful decrease of resistance helped the parents to make s t r i k i n g , p o s i t i v e changes i n the family s i t u a t i o n i n f i v e of the s i x cases upon completion of the intake study. There was some degree of p o s i t i v e movement i n the s i x t h case. The successful handling of the resistance benefited the c h i l d i n f i v e , i f not a l l , of the s i x cases. A tabulation of the worker's a c t i v i t y which res u l t e d i n a decrease i n resistance demonstrated that there were "common denominators" present. E a r l y recognition of the resistance by the worker was not recorded as part of the a c t i v i t y , because the resistance was so marked as to be obvious, since withdrawal was openly contemplated. The worker's a c t i v i t y with t h i s p a r t i c u l a r group of c l i e n t s could be summarized i n t h i s way: A favorable "climate" was provided f o r the r e s i s t i n g parent so that she might express her thoughts and f e e l i n g s and have them accepted. This - 8 6 -condition was "aggressively" and p e r s i s t e n t l y brought to the resisting; c l i e n t , through the use of home v i s i t s , s p e c i a l l y timed appointments and i n i t i a t i o n of telephone c a l l s , i f necessary. There was no mysterious and complicated handling of defense mechanisms by subtle i n t e r p r e t a t i o n , • or c l a r i f i c a t i o n . The defensiveness was simply accepted. The expression of i t was aided by the p e r s i s t e n t o f f e r of help, explanation of agency function, and way of carrying out t h i s function, together with a gentle re-focusing on some aspect of the problem not previously discussed. The worker sustained the client-worker r e l a t i o n s h i p as being one of safety and dependability. Apparently, when a parent f e e l s s a f e — a c c e p t e d as she i s , — a genuine and firm o f f e r of help does stimulate her to express i n t e l l e c t u a l and emotional f a c t s about her d i f f i c u l t y , when she i s encouraged to do so. The worker accepted whatever the c l i e n t was able to t a l k about: h e r s e l f , her neighbours, the doctor, the teacher, the c h i l d , and so on. P o s i t i v e , mixed, and e s p e c i a l l y negative f e e l i n g s were accepted. A minimum amount of the problem-solving part of the interviews was begun; the problem was discussed i n one aspect and the worker shared her own and the c l i e n t ' s perspective. Then something d i d happen. Perceiving the problem d i f f e r e n t l y and, i n e x t r i c a b l y combined with t h i s , f e e l i n g d i f f e r e n t l y about i t , the parent reacted d i f f e r e n t l y to the problem and there was p o s i t i v e movement. This occurred i n spite of the fac t that extremely l i t t l e c l a r i f i c a t i o n was used, and suggestions by the worker - 87 -were at a minimum, and were given only i n response to a d i r e c t request f o r them. This might be viewed as a way of accepting defensiveness. While i t i s recognized that many c l i e n t s who ask f o r advice, are r e s i s t i n g involvement i n seeking a s o l u t i o n and may therefore have to prove that the worker's advice i s not h e l p f u l , the seeking of advice i s at l e a s t a response from the parent. Apparently i t may be responded to without adverse e f f e c t on the t o t a l p attern of decreasing resistance, provided the suggestions were given only i n response to a request, and were only r e l a t e d to a l i m i t e d aspect of the problem. Added to t h i s , i n order to increase i t s e ffectiveness, would be the r e p e t i t i o n of the whole pattern of the worker's a c t i v i t y , p a r t i c u l a r l y the explanation of agency function and the need f o r the parents' p a r t i c i p a t i o n . The l a t t e r two explanations are s i g n i f i c a n t l y discussed i n a concurrent study of premature withdrawals from treatment: Laidman"''suggested that these'very explanations were not given i n d e t a i l , or i n simple jargon-free language, or were not repeated. These findings give strength to the conclusions of t h i s study. The parent needs to know what the worker i s doing and how, and why she i s doing i t , and i n words she can understand. When discussing the i n d i c a t o r s of withdrawal of parents from the agency, Laidman points out that the reassignment of cases upon completion of the intake study i s a Laidman, Ward op c i t . - 88 -d i s s a t i s f a c t o r y experience f o r many c l i e n t s . He suggests that c l i e n t s need to express t h e i r f e e l i n g s about i t and have them accepted and that more time should be given to t h i s t r a n s f e r of workers. The pattern f o r t h i s a b i l i t y to express f e e l i n g s and have them accepted i s outl i n e d early i n the intake study that i s handled e f f e c t i v e l y . A simple but d e t a i l e d explanation of the t r a n s f e r and the worker's alertness about providing opportunities f o r the expression of d i s s a t i s f a c t i o n should enable the parent to externalize the negative f e e l i n g s . The Laidman study concludes that the major conscious reason f o r parents' discontinuation i s the waiting period between the intake study and treatment. Because there was no actual waiting period i n the cases studied'here, t h i s f a c t o r i t s e l f i s apparently of considerable importance i n keeping c l i e n t s i n treatment. In view of the f a c t that the waiting period appears to be an administrative necessity i n most cases, Laidman suggested that the continued service worker could keep a f i l i n g system of those cases which are assigned f o r future treatment and telephone them r e g u l a r l y during the waiting period. The worker might even arrange a single interview to help the parents over a p a r t i c u l a r obstacle, i f necessary. This suggestion i s i n agreement with the findings of e f f e c t i v e a c t i v i t y i n decreasing resistance. The i n i t i a -t i o n of telephone c a l l s by the worker assures the parent of the continued i n t e r e s t of the agency s t a f f and of t h e i r desire to help. It may well help the c l i e n t t e s t out new strengths and consolidate gains made during the intake study, as Laidman has - 8 9 -suggested. It seems c l e a r from the extent of case withdrawals from the agency that unless measures are implemented during the waiting period such as those suggested by Laidman, there w i l l be a high rate of discontinuation. These cases w i l l not receive treatment at a l l unless the continued service worker could duplicate the time-consuming process of decreasing .. i n i t i a l resistance again. Much of the time-consuming part of the pattern would not have to be repeated i n i t s e n t i r e t y i f the client-worker r e l a t i o n s h i p could be supported i n some way, so that the nurturing, healing, helping q u a l i t i e s of the r e l a t i o n s h i p could be maintained throughout the waiting period. It seems evident that one cannot take a bond of t h i s import-ance and break i t , even f o r admin i s t r a t i v e l y sound reasons, and expect that the c l i e n t with weak ego-strengths w i l l emotionally understand it."'" It appears that a decision needs to be made at diagnostic .conference regarding whether the parents with t h e i r present strengths, and t h e i r pattern of resistance, need to be given treatment immediately, or i f they are s u f f i c i e n t l y strong to be helped by the b r i e f kind of contacts during the waiting period which Laidman has suggested. To be re a l l y , h e l p f u l , the worker must see the agency and i t s p a r t i c u l a r way of carrying out i t s f u n c t i o n as the c l i e n t sees i t . This l a t t e r point i s discussed i n Chapter IV of the Laidman study, i b i d . - 90 -Two other common elements were present i n the cases studied; the father was seen and h i s p a r t i c i p a t i o n was encouraged, and furthermore, the other people of importance i n the s i t u a t i o n were contacted, the teacher, the p r i n c i p a l , the doctor and so on. Pollack"'" makes reference to the si g n i f i c a n c e of these c o l l a t e r a l contacts i n decreasing the resistance of parents. This was discussed i n Chapter I. Another common element i n the s e l e c t i o n was the f a c t o r of l i m i t e d treatment goals. This may be s i g n i f i c a n t i n that the worker apparently had a sound diagnostic base with which to view treatment. In addition, the worker's expectations of the c l i e n t would be i n accordance with her c a p a c i t i e s , and every step forward would be met with i n t e r e s t and support. Conclusion: Any c l i e n t ' s t r e a t a b i l i t y i s i n large measure governed by her capacity to involve h e r s e l f i n the helping process. This capacity of the parent to involve h e r s e l f i n treatment i s apparently influenced i n large measure by the worker's a c t i v i t y . This knowledge places a r e s p o n s i b i l i t y on the s o c i a l worker to assess her own motivation, her own con-v i c t i o n or strength of desire to help, i n f a c t , her possible resistance to creating;the conditions under which the parent can use help. I n i t i a l Resistance i n other settings - - • Whatever knowledge i s v a l i d f o r decreasing resistance "'"Pollack, Otto - op c i t . - 9 1 -i n one agency se t t i n g w i l l have value i n other agencies and s i t u a t i o n s as w e l l . The c l i e n t who comes to a p u b l i c agency f o r s o c i a l assistance i s frequently i n c o n f l i c t about the request. The pattern of a c t i v i t y o u t l i n e d as apparently e f f e c t i v e i n decreasing the i n i t i a l resistance of parents to casework services i n a c h i l d guidance s e t t i n g , w i l l prove e f f e c t i v e i n many ways i n the public welfare s e t t i n g . The explanation of agency function, the simple d e t a i l e d explanation of the way i n which the agency c a r r i e s out i t s function, and f o r what reasons, the need f o r the c l i e n t to play an active r o l e i n the procedures, the acceptance of defensiveness, gently re-focusing upon some aspect of the problem, with a d e t a i l e d r e p e t i t i o n of the former a c t i v i t y i f n e c e s s a r y — o f f e r i n g the help i n a f i r m and p e r s i s t e n t w a y — g e t t i n g the service to the c l i e n t . The actual "outgoingness" of telephone c a l l s and home v i s i t s would also be valuable i n t h i s regard. These factors would be equally valuable i n a c o r r e c t i o n a l s e t t i n g where the offender u s u a l l y does not want help, nor see the need f o r i t . The consistent o f f e r of s e r v i c e , using the s p e c i f i c a c t i v i t y outlined, together with the authority the worker has, which gives him not only the r e s p o n s i b i l i t y but the l e g a l r i g h t to do so, w i l l surely help many offenders to become involved i n treatment. This would be e s p e c i a l l y important i n a probation s e t t i n g where the help offered i s through the medium of a r e l a t i o n s h i p i n an interview s i t u a t i o n . The f i r m l i m i t a t i o n s which are necessary i n the c o r r e c t i o n a l s e t t i n g , w i l l s urely prove more e f f e c t i v e - 9 2 -when accompanied "by, or preceded "by, the use of s o c i a l work methods and techniques which are e f f e c t i v e i n decreasing i n i t i a l resistance. The worker i n an agency which gives l e g a l p r o t e c t i o n to c h i l d r e n i s frequently faced with the problem of t r y i n g to help parents who do not want help. Decreasing i n i t i a l r e s i s t -ance by a c t i v i t y s i m i l a r to that o u t l i n e d as succesful i n a c h i l d guidance s e t t i n g should also prove e f f e c t i v e i n i n v o l v i n g the family i n services i n s p i t e of themselves. The knowledge should prove equally u s e f u l i n r e h a b i l i t a t i o n programs and medical s e t t i n g s . L'- . The l i m i t a t i o n s of a study with a random sample and with conclusions which depend upon the judgement of the author are recognized. There i s a need f o r further research i n t h i s area, p a r t i c u l a r l y f o r a study to examine a d i f f e r e n t group of parents who are perhaps s e l f r e f e r r e d . This might r e s u l t i n discovering a pattern of worker's a c t i v i t y which has more c l a r i f i c a t i o n i n i t , and where there might be conditions where the p e r s i s t e n t resistance could be openly discussed with the c l i e n t , with b e n e f i c i a l r e s u l t s . Perhaps the t r e a t a b i l i t y of c l i e n t s should be thought of less i n terms of t h e i r apparent motivation, and more i n terms of t h e i r capacity,"*"and what conditions w i l l enable them to use t h e i r capacity. 1 Levy, David M., "Capacity and Motivation", p . l , American  Journal of Ortho Psychiatry, Volume 2 7 , No. 1 , January,1957* Appendix A 93 Bibliography Books: Pollack, Otto, Social Soienoe and Psyohotheraphy for Children, Russel Sage Foundation, New York, 1952. Pollack, Otto, Integrating Socialogical and Psychoanalytic Concepts, Russel Sage Foundation, New York, 1956. Hamilton, Gordon, Psychotherapy in Child Guidance, Columbia University Press, New York, 1947. Hamilton, Gordon, Theory and Practice of Social Casework, Columbia University Press, 1951. Freud, Sigmund, The Problem of Anxiety, Psychoanalytic Quarterly Press and W.W. Norton Inc., New York, 1936. Freud, Anna, The Ego and Mechanisms of Defense, International Universities Press Inc., New York, 1946. Kasius, Cora, A Comparison of Diagnostic and Functional Concepts, F.S.A.A., New York. Fenichel, Otto, The Psychoanalytic Theory of Neurosis, W.W. Norton & Co., Inc. New York, Pages 140 - 167, 1945. Wolberg, Lewis R., The Technique of Psychotherapy, Grune and Stratton, New York, 1954, Chapters 28 "Dealing with Inadequate Motivation", 31 "Establishing A Working Relationship", 41, The Handling of Resistances to Cure". Hunt, J, McV., Measuring Results in Social Casework, Family Service and Association of America, New York, 1950. Kogan, Leonard S., French, David, An Approach to Measuring Results in Social Casework, Columbia University Press, New York, 1952. Towle, Charlotte, Social Case Records From Psychiatric Clinics, University of Chicago Press, I l l i n o i s , 1942. Articles: Perlman, Helen Harris, "The Basic Structure of the Casework Process," Social Service Review, September 1953, p. 308. Perlman, Helen Harris, "Client's Treatability," Journal of the National  Association of Social Workers, Ootober, 1956, p. 32. Willsnack, William H, "Handling Resistance in Social Work," American  Journal of Orthopsychiatry, Vol. 16, April 1946, p. 297. 94 Allen, Frederick H., "Creation and Handling of Resistance in C l i n i c a l Practice," American Journal of Orthopsychiatry, Vol. 2, July 1932, p. 268. Overton, Alice, "Serving Families who 'Don't Want Help'", Journal of Social  Casework, July 1953, p. 304. • Garrett, Annette, "The Worker-Client Relationship," American Journal of  Orthopsychiatry, 1949, p. 224. ' Lane, Lionel C , Aggressive Approach in Preventive Casework with Children's Problems, Journal of Sooial Casework, February, 1952, p. 65. Allport, Gordon, "The Trend in Motivational Theory," American Journal of  Orthopsychiatry, January, 1953, p. 107. Hofstein, Saul, "Sooial Factors in Assessing Treatability in Child Guidance," Vol. 4, No. 2, March-April 1957, p. 48, Children. Levy, David M., "Capacity and Motivation," American Journal of Orthopsychiatry, Vol. 27, No. 1, January, 1957, p . l . Bergum, Mildred, "The Father Gets Worse,""A Child Guidance Problem," American Journal of Orthopsychiatry, Vol. 12, July 1942, p. 474. Biestek Felix, "An Analysis of the Casework Relationship," Journal of  Social Casework, February, 1954. Aptehar, Herbert, "The Concept of Resistance," The Family, February, 1938. Hirsohn, Sid, "Casework with the Compulsive Mother," Journal of Social  Casework, Vol. 32, 1951, p. 259. Abrahamson, Arthur C., "The Supervisory Process in Public Welfare", Public Welfare, Volume 13, No. 2, April, 1955. Menninger, William, Mimeographed material edited by the School of Social Work, University of B r i t i s h Columbia, t i t l e d Fundamentals of  Psychiatry. Exner, Helen, K., Mimeographed material regarding the Principles and Concepts of Social Work, 1956. .v Recording Committee Notes, Child Guidance C l i n i c , Burnaby, June 1956. Other Studies: Glover, Geoffrey, Casework Interviewing Methods in a Child Guidance  Sett ing, M.S.?/. Thesis, University of Bri t i s h Columbia, 1951. Daly, Katherine, Evaluating the Modiflability of the Client; One Factor in Determining Treatability, M.S.W. Thesis, University 'of British Columbia, 1955. 95 Fogarty, Patrick, Relation of Children's Disorders to Limiting Parental Influences, M.S.W. Thesis, University of British Columbia, 1952. Chave, Estelle, The Pre-Clinical Conference, As A Diagnostic Screen In The Child Guidance Setting, M.S.W. Thesis, 1952. Flores, Helen, Resistance as an Indicator of Motivation,M.S.W. Thesis, Smith College Studies, 1954. Laidman, Ward, Premature Withdrawals from Treatment in a Child Guidance Agency, M.S.W. Thesis, University of Br i t i s h Columbia, 1957. Roberts, Evelyn M., Mental Health Services, M.S.W. Thesis, University of B r i t i s h Columbia, 1949. Coyle, Phyllis, Travelling Psychiatric Services, M.S.W, Thesis, University of British Columbia, 1955. Beck, Dorothy, Resistance of the Adolescent to Casework Services, M.S.W, Thesis, University of Br i t i s h Columbia, 1954. Mackenzie, Budd, The Play Interview as a Social Work Technique in a Child Guidance Setting, M.S.W. Thesis, University of B r i t i s h Columbia, 1956. * * * * 

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