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Premature withdrawal from treatment in a child guidance clinic : an exploratory study of the factors… Laidman, Leslie Warde 1957

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PREMATURE WITHDRAWAL FROM TREATMENT IN A CHILD GUIDANCE CLINIC An Exploratory Study of the Factors Which Underlie Clients' Decisions to Withdraw From.Social Work Treatment at the Provincial Child Guidance Clinic, North Burnaby, B.C*  by  LESLIE WARDE LAIDMAN  Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of . MASTER OF SOCIAL WORK in the School of Social Work  Accepted as conforming to the standard required for the degree of Master of Social ¥ork  School of Social Work  1957  The University of British Columbia  iii ABSTRACT T h i s i s an e x p l o r a t o r y study of the problem of c l i e n t s ' d i s c o n t i n u a t i o n i n a c h i l d guidance c l i n i c . The problem i s cons i d e r e d f i r s t i n terms of i t s t h e r a p e u t i c and a d m i n i s t r a t i v e imp l i c a t i o n s f o r c l i e n t s and. s o c i a l workers. Reference i s made t o the p r o f e s s i o n a l l i t e r a t u r e which suggests the m u l t i - c a u s a t i v e f a c t o r s which operate i n a c l i e n t ' s d e c i s i o n to withdraw from soci a l work s e r v i c e s . The problem i s a l s o r e l a t e d t o s o c i a l work p r i n i c p l e s and concepts. T h i s i s done t o demonstrate t h a t , by t h e i r c o n t i n u e d e f f o r t s t o understand the meaning of behaviour, to study the c l i e n t i n as much o f h i s t o t a l l i f e s i t u a t i o n as poss i b l e , and t o r e f i n e and e n r i c h methods of f a m i l y d i a g n o s i s , soci a l workers can sharpen t h e i r d i a g n o s t i c s k i l l s and t h e i r a b i l i t y to s e l e c t e f f e c t i v e treatment g o a l s . A b r i e f d i s c u s s i o n o f the h i s t o r y of c h i l d guidance t o g e t h e r w i t h a more d e t a i l e d account of 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 North Burnaby g i v e s a broad p e r s p e c t i v e t o the problem of d i s c o n t i n u a t i o n . The problem i s i l l u s t r a t e d i n f i v e s e l e c t e d cases i n which c l i e n t s withdrew themselves and t h e i r c h i l d r e n from C l i n i c services. The case r e c o r d s a r e examined, h i g h l i g h t i n g both dynamic p a t t e r n s w i t h i n the " i n d i v i d u a l f a m i l i e s and a l s o t h e i r a t t i t u d e s towards the c h i l d ' s problems and t h e i r C l i n i c e x p e r i e n c e s . These areas a r e thought t o be s i g n i f i c a n t f a c t o r s r e l a t i n g to the p a r e n t s ' d e c i s i o n s t o withdraw. F i v e f o l l o w - u p i n t e r v i e w s a r e conducted and r e c o r d e d which i n d i c a t e the c l i e n t s ' v e r b a l r e a c t i o n s t o t h e C l i n i c , i n c l u d i n g t h e i r conscious reasons f o r withdrawal. An assessment i s made of the degree of C l i n i c h e l p which the f i v e f a m i l i e s were a b l e t o employ. Common p a t t e r n s a r e e l u c i d a t e d i n the f i v e cases and a r e designated as "withdrawal i n d i c a t o r s " . These i n d i c a t o r s may, i n the f u t u r e , have p r o g n o s t i c v a l u e i n d e t e r m i n i n g which cases a r e l i k e l y t o withdraw. The i n d i c a t o r s a r e a p p l i e d t o s i x a d d i t i o n a l cases ( t a b u l a t e d i n Appendix D). The r e s u l t s show t h a t t w o - t h i r d s of the i n d i c a t o r s a r e p r e s e n t i n each o f t h e s i x c a s e s . A f u r t h e r study i s recommended i n which the i n d i c a t o r s would be a p p l i e d t o a l a r g e r number of d i s c o n t i n u e d cases, thus d e t e r m i n i n g t h e i r r e l i a b i l i t y as p r e d i c t i v e t o o l s . The c l i e n t s ' reasons f o r w i t h drawal a r e d i s c u s s e d t o g e t h e r w i t h the recommendation t h a t an add i t i o n a l study be done both t o v a l i d a t e these reasons and t o demonstrate new ones. In l i g h t o f the f i n d i n g s v a r i o u s recommendations a r e made which the C l i n i c s o c i a l work s t a f f might implement i n an attempt t o decrease the r a t e of d i s c o n t i n u a t i o n . The withdrawal i n d i c a t o r s should be r e c o g n i z e d as forms of r e s i s t a n c e and should  iv  be handled by the workers i n e a r l y i n t e r v i e w s . Increased s k i l l s i n the areas of f a m i l y d i a g n o s i s and a more d i s c r i m i n a t i n g system of r e c o r d i n g w i l l h e l p t o expedite the workers' r e c o g n i t i o n of the i n d i c a t o r s . A l s o , g r e a t e r s k i l l by the workers i n r e c o g n i z i n g b r i e f s e r v i c e cases, i n h a n d l i n g reassignment, i n t h e i r i n t e r p r e t a t i o n of the C l i n i c and i t s f u n c t i o n s , and i n t h e i r c h o i c e of words, w i l l h e l p t o strengthen the c l i e n t s ' m o t i v a t i o n t o a continued C l i n i c c o n t a c t . Recommendations a r e a l s o made whereby the w a i t i n g - p e r i o d , which emerges as the s t r o n g e s t reason f o r d i s c o n t i n u a t i o n , might be u t i l i z e d as a t h e r a p e u t i c t o o l i n treatment. Withdrawal must, i n n e a r l y a l l cases, r e f l e c t t h e c l i e n t s ' d i s s a t i s f a c t i o n s w i t h the s e r v i c e s of the C l i n i c . To a t t a i n t h e i r goals f o r t h e i r c l i e n t s , the agency, and themselves, the C l i n i c soci a l workers must s t r i v e t o understand and decrease the r a t e of d i s continuation.  In p r e s e n t i n g the  this thesis in partial fulfilment  requirements f o r an advanced degree at the  of  University  o f B r i t i s h Columbia, I agree t h a t the  L i b r a r y s h a l l make  it  study.  f r e e l y available f o r reference  and  I  further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may  be granted by the  Department o r by h i s r e p r e s e n t a t i v e .  Head o f  my  I t i s understood  t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not  be allowed without my  The U n i v e r s i t y of B r i t i s h Vancouver &*, Canada.  Columbia,  written  permission.  V  ACKNOWLEDGEMENTS The w r i t e r wishes t o express a p p r e c i a t i o n t o Dr. U. P. Byrne, D i r e c t o r o f the C h i l d Guidance C l i n i c f o r permiss i o n t o use C l i n i c r e c o r d s as case m a t e r i a l f o r t h i s study; t o Miss K a t h e r i n e Daly, S u p e r v i s o r of the Intake and B r i e f S e r v i c e s S e c t i o n f o r the warm i n t e r e s t i n the p r o j e c t and f o r h e r suggestions and c o n s t r u c t i v e c r i t i c i s m s which r e f l e c t h e r f a i t h i n the p r i n c i p l e s of S o c i a l Work. S p e c i a l acknowledgement i s made t o Miss M u r i e l Cunl i f f e o f the School of S o c i a l Work f o r her c o n s i s t e n t h e l p f u l n e s s and guidance which f a c i l i t a t e d the w r i t i n g o f t h i s t h e s i s and which enhanced the w r i t e r ' s t h e o r e t i c a l and p r a c t i c a l knowledge of S o c i a l Work as a whole; t o Mr. A d r i a n Marriage o f the School of S o c i a l Work f o r h i s support and s t i m u l a t i n g c r i t i c i s m which c o n t r i b u t e d g r e a t l y to the w r i t e r ' s c o n t i n u i n g i n t e r e s t i n the study.  ii TABLE OF CONTENTS Chapter 1. The Problem o f D i s c o n t i n u a t i o n C h i l d Guidance S e t t i n g  ina  D i s c o n t i n u a t i o n and i t s r e l a t i o n t o treatment. E v o l u t i o n o f the s o c i a l workers r o l e i n the treatment of c h i l d r e n and p a r e n t s . S o c i a l Work p r i n c i p l e s i n the present study. F a m i l y - c e n t e r e d casework. Functions of the North Burnaby C l i n i c . Types of s e r v i c e s . Diagnostic E v a l u a t i o n p e r i o d . S o c i a l S e r v i c e Department. Focus of the study Chapter 2 .  22  The Common Denominator.  Nine "Withdrawal I n d i c a t o r s " as found i n the f i v e case summaries. A p p l i c a t i o n of the i n d i c a t o r s t o s i x add i t i o n a l cases. V a l i d i t y of the reasons f o r withdrawal as s t a t e d by the c l i e n t s i n the follow-up i n t e r v i e w s . Five reasons f o r withdrawal Chapter 4 .  1  The Reasons f o r D i s c o n t i n u a t i o n .  Methodology o f the present study. F i v e case summaries. F i v e follow-up i n t e r v i e w s . I m p l i c a t i o n s of the i n t e r v i e w s . Was the C l i n i c h e l p f u l ? Chapter 3 .  Page  Toward  58  Continuation.  Withdrawal i n d i c a t o r s as r e s i s t a n c e . Need f o r r e c o g n i t i o n of r e s i s t a n c e i n e a r l y c o n t a c t s . Need f o r g r e a t e r emphasis on f a m i l y p a t t e r n s and a d i s c r i m i n a t i n g system of r e c o r d i n g . S k i l l i n recognizing b r i e f service cases. Reassignment. Ways of h a n d l i n g c l i e n t s ' expecta t i o n s o f concrete s e r v i c e s . Therapeutic use o f the w a i t i n g period. Conclusions. 78 Appendices. A. L e t t e r to C l i e n t t o i n t r o d u c e the follow-up interview.... B. Schedule f o r case summaries • C. Schedule f o r follow-up i n t e r v i e w w i t h c l i e n t D. Table of frequency of withdrawal i n d i c a t o r s i n s i x a d d i t i o n a l cases E. Bibliography.  90 Ql 92 93 94  CHAPTER I  The Problem of D i s c o n t i n u a t i o n i n a C h i l d Guidance S e t t i n g "The  g o a l of treatment  i n casework i s to s t a b i l i z e or to  improve the f u n c t i o n i n g of the c l i e n t i n terms of s o c i a l  adaptation  1 or adjustment, e s p e c i a l l y i n the balance  of i n n e r and  outer f o r c e s . "  Treatment goals are s e l e c t e d on the b a s i s of study and which occur i n the n a t u r a l progress of each case. all  treatment  must be based on t h i s study  p s y c h o l o g i c a l , p h y s i c a l , economic, and  diagnosis  To be  helpful  and d i a g n o s i s i n which  s o c i a l f a c t o r s are  as i n t e r a c t i n g i n v a r i o u s p r o p o r t i o n s i n the t o t a l l i f e of a c l i e n t .  situation  T h i s i s termed the p s y c h o s o c i a l approach to  d i a g n o s i s , and  considered  study,  treatment.  An anomalous s i t u a t i o n a r i s e s i n c h i l d guidance when c l i e n t s d i s c o n t i n u e treatment. not r e a l i z e d . diagnosed,  The  T h i s means t h a t treatment  goals  c l i e n t s ' problems, which have been s t u d i e d and  do not reach the l e v e l of improvement which the  pro-  f e s s i o n a l worker r e c o g n i z e d as being r e a l i s t i c a l l y p o s s i b l e .  In  s h o r t , both the c l i e n t and  the worker emerge from an incomplete  p e r i e n c e or r e l a t i o n s h i p .  The  h e l p and may  are  c l i e n t may  continue t o f i n d unhealthy  o f t e n wonder why  What, i t may  s k i l l s and  sought  ways of h a n d l i n g h i s p r o -  blems; the worker, i n the l i g h t of d i s c o n t i n u a t i o n , may q u e s t i o n both h i s own  he  ex-  tend to  the o r i g i n a l d i a g n o s i s .  be asked, are the c a u s a t i v e f a c t o r s  Hamilton, Gordon, Theory and P r a c t i c e of S o c i a l Casework. Revised E d i t i o n , Columbia U n i v e r s i t y P r e s s , New York, 1951, p. 23?.  u n d e r l y i n g withdrawal? a l p o s s i b l e answers.  A moment's r e f l e c t i o n w i l l  i n d i c a t e sever-  The e n t i r e a r e a of c l i e n t r e s i s t a n c e to  treatment must be c o n s i d e r e d - an a r e a which c o n s t i t u t e s  sufficient  1 m a t e r i a l f o r numerous r e s e a r c h p r o j e c t s . that a c l i e n t w i l l  sometimes d i s p l a c e h i s own  h a v i o u r of a c h i l d or spouse. by withdrawing  Gordon Hamilton  f a i l u r e s on the be-  The c l i e n t s w i l l r e s i s t  "as soon as they take i n how 2  suggests  treatment  they themselves  will  be i n v o l v e d i n treatment." A change i n workers can be a traumatic experience t o the c l i e n t and thus i n s t r u m e n t a l i n h i s withdrawal from T h i s i n v o l v e s the complex phenomenon of t r a n s f e r e n c e .  treatment. "When we  c o n s i d e r the t r a n s f e r e n c e and i t s e s s e n t i a l l y dependent,  irrat-  i o n a l n a t u r e , i t i s immediately e v i d e n t t h a t the d i s r u p t i o n of the casework r e l a t i o n s h i p can be of the utmost s i g n i f i c a n c e to the 3 client."  I n other words, some c l i e n t s who  have a f r u s t r a t e d  de-  pendence on workers w i l l break c o n t a c t w i t h the agency a t the p o i n t of reassignment. same way  In e f f e c t , they are r e j e c t i n g the agency i n the  as t h e i r worker r e j e c t e d them.  "such behaviour may  Miss F l e s c h says t h a t  conceal a deeper r e q u e s t f o r s e r v i c e , the c l i e n t ' s  wish t o be pursued and g i v e n assurance of h i s worth and 4 worker's a f f e c t i o n . "  the  1  For o n e aspect see Beck, Dorothy, R e s i s t a n c e of the A d o l escent to Casework S e r v i c e s . U n i v e r s i t y of B r i t i s h Columbia MSW T h e s i s , 1954. 2  Hamilton, Gordon, Op. C i t . . p. 57  3 signment  F l e s c h , Regina, Treatment C o n s i d e r a t i o n s i n the Reasof C l i e n t s . F.S.A.A., New York, 1947, p. 14 4 F l e s c h , Regina, I b i d , p. 16  3 Lawson Lowrey suggests another r a m i f i c a t i o n of r e a s s i g n ment:  "Changes i n and  absence of s t a f f f o r whatever reasons o f t e n  l e a d the c l i e n t to doubt t h a t he and h i s problems are regarded 1 important."  Such a b e l i e f by  as  the c l i e n t would seemingly m i l i t a t e  a g a i n s t c o n t i n u a t i o n i n treatment. In a d d i t i o n to the complex p s y c h o l o g i c a l aspects c l i e n t - d i s c o n t i n u a t i o n there may  w e l l be  the more p r a c t i c a l  which can not be p r e d i c t e d a t the o u t s e t . to the treatment s e r v i c e may  of reasons  Geographic a c c e s s i b i l i t y  change; s i c k n e s s may  from c o n t i n u i n g i n treatment; or the c l i e n t may  prevent the  consciously  s i n c e r e l y b e l i e v e t h a t he has been s u f f i c i e n t l y helped  to  client  and  the  p o i n t where he can cope s a t i s f a c t o r i l y w i t h h i s problem. Withdrawal from treatment i s of concern to c h i l d guidance s t a f f i n terms of both i t s s e r v i c e s and c l i e n t must i n c l u d e h e l p . continue help by  and  A s e r v i c e to a  T h i s help i s l a c k i n g when c l i e n t s  f o r p s y c h o l o g i c a l reasons.  Here, the f i r s t  the o r i g i n a l d i a g n o s i s and  their  consideration  treatment p l a n .  r e a l i s t i c i n terms of a dynamic d i a g n o s i s ?  i s necessary b e f o r e a c c u r a t e  Was  i t sound  A dynamic d i a g n o s i s  treatment g o a l s r e l a t i n g to the  v i d u a l needs of the c l i e n t can be e s t a b l i s h e d .  Diagnosis  treatment goals do change, and r i g h t l y so, as the strengths and weaknesses become d e f i n e d . needs to be c e r t a i n t h a t a l l aspects  dis-  This r e c o g n i t i o n of l a c k of  the s t a f f w i l l n a t u r a l l y cause them to q u e s t i o n  s k i l l s as p r o f e s s i o n a l workers. might be  skills.  indi-  and  client's  The worker,  of the c l i e n t ' s  nevertheless, amenability  _  Lowery, Lawson G., P s y c h i a t r y f o r S o c i a l Workers. Second E d i t i o n , Columbia U n i v e r s i t y P r e s s , New York: 1 9 5 0 , pp. 352-3  4  to treatment are r e c o g n i z e d and c o n s i d e r e d d u r i n g the d i a g n o s t i c evaluation period. S o c i a l work s t a f f a t 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 Burnaby, B r i t i s h Columbia, have expressed  concern w i t h the e f -  f e c t which the w a i t i n g - p e r i o d might have on c l i e n t s .  The  length  and p o s i t i o n of the w a i t i n g - p e r i o d w i l l vary from c l i n i c to At the Burnaby C l i n i c there i s u s u a l l y a s h o r t wait a f t e r and a more prolonged Could  one between d i a g n o s t i c and  t h i s more prolonged  clinic.  referral  continued s e r v i c e s .  wait be a f a c t o r i n withdrawal from  treatment?  T h i s would seem reasonable,  p a r t i c u l a r l y with  c l i e n t s who  have s t r o n g , unmet dependency needs.  those  To them, a l o n g  w a i t i n g - p e r i o d c o u l d seem i n t o l e r a b l e - a r e j e c t i o n of t h e i r problem by  the agency.  A l o n g wait c o u l d a l s o be p a r t i c u l a r l y d i s t u r b -  i n g f o r the c l i e n t to whom making the d e c i s i o n to seek h e l p crucial.  "The 1  was  r e s u l t of such f r u s t r a t i o n i s o f t e n l a c k of impetus  to proceed." The  d i s c u s s i o n t h i s f a r would suggest t h a t the problem  of d i s c o n t i n u a t i o n has both t h e r a p e u t i c and a d m i n i s t r a t i v e cations:  impli-  t h e r a p e u t i c i n so f a r as treatment g o a l s based on d i a g -  n o s i s are not r e a l i z e d ; and a d m i n i s t r a t i v e i n t h a t the workers' time and  s k i l l s are perhaps not b e i n g u t i l i z e d  to the most d e s i r -  able degree of e f f e c t i v e n e s s . In t h i s study,  i t i s proposed to examine s e v e r a l  cases  i n which c l i e n t s have d i s c o n t i n u e d treatment i n a c h i l d guidance setting.  I t should be  s t r e s s e d , however, t h a t the problems of  d i s c o n t i n u a t i o n or withdrawal from treatment are not i s o l a t e s 1 Lowery, Lawson. I b i d . . p.  352  but  have evolved w i t h the h i s t o r y of c h i l d guidance c l i n i c s as a whole.  To p r o v i d e the reader w i t h a broader p e r s p e c t i v e , some  d i s c u s s i o n of the h i s t o r i c a l a s p e c t s of the C h i l d Guidance  1 •  ment^  i s necessary, emphasizing  the e v o l u t i o n of the  Move-  social  worker's r o l e i n the treatment of c h i l d r e n and p a r e n t s .  This w i l l  a l s o g i v e the r e a d e r a b e t t e r understanding of s o c i a l work t r e a t ment i n c h i l d guidance and a c l e a r e r i m p r e s s i o n of what c l i e n t s are withdrawing  'from', when they d i s c o n t i n u e .  The c h i l d guidance c l i n i c owes i t s o r i g i n to such men A d o l f Meyer, W i l l i a m A. White, Thomas W.  as  Salmon, and o t h e r s o c i a l  p s y c h i a t r i s t s who, a t the b e g i n n i n g of the century "were i n s i s t i n g on a study of the whole i n d i v i d u a l , h i s environment and h i s r e a c t 2 ions to i t . " uniqueness  Meyer's b a s i c c o n t r i b u t i o n was  h i s emphasis on the  of each i n d i v i d u a l p a t i e n t and the consequent  necessity  of s t u d y i n g h i s t o t a l l i f e h i s t o r y as w e l l as h i s i n t e l l e c t u a l p h y s i c a l equipment i f one disorder.  and  i s to understand the nature of h i s p r e s e n t  T h i s p o i n t of view assumes t h a t mind and body are i n a  s t a t e of constant i n t e r a c t i o n and that mental a c t i v i t y and behavi o u r r e p r e s e n t the adjustment  of the i n d i v i d u a l as a whole.  "From  F r e u d i a n theory came the concept of the dynamic i n f l u e n c e s of the emotions  (the i n d i v i d u a l ' s own  and those of the persons w i t h whom  3 he i s i n c o n t a c t ) on human behaviour,"  Freud showed behaviour to  1 For supplementation, see: Chave, E s t e l l e , The Pre C l i n i c a l Conference as a D i a g n o s t i c Screen i n the C h i l d Guidance S e t t i n g , U n i v e r s i t y Of B r i t i s h Columbia MSW T h e s i s , 1952.  2  T r u i t t , Ralph P., "Community C h i l d Guidance C l i n i c s " , The C h i l d Guidance C l i n i c and the Community. The Commonwealth Fund, D i v i s i o n of P u b l i c a t i o n s , 1928, p. 2 .  3  Witmer, Helen, P s y c h i a t r i c C l i n i c s f o r C h i l d r e n . Commonwealth Fund, New York, 1 9 4 0 , p. 3 3 ?  The  6 be p u r p o s i v e .  I t s purpose, however, may be i n response t o the  needs o f the unconscious and w i l l ional.  t h e r e f o r e appear to be i r r a t -  The work of these men r e s u l t e d i n our p r e s e n t c h i l d  guid-  ance approach, the essence of which i s the m u l t i - c a u s a t i o n concept of b e h a v i o u r . W i l l i a m Healy, e a r l y i n the century made an o u t s t a n d i n g c o n t r i b u t i o n t o the growth o f t h i s i d e a .  He i n s i s t e d on a concen-  t r a t e d study from the m e d i c a l , p s y c h o l o g i c a l , and s o c i a l p o i n t s o f view upon y o u t h f u l o f f e n d e r s "with -the aim o f s e a r c h i n g out the causes of t h e i r misbehaviour and f i n d i n g ways o f p r e v e n t i n g them  1 from d e v e l o p i n g i n t o a d u l t c r i m i n a l s . "  The Chicago J u v e n i l e Psy-  chopathic I n s t i t u t e , founded by him i n 1909 was u n q u e s t i o n a b l y the p i o n e e r i n t h i s f i e l d and p r o v i d e d the p a t t e r n on which the l a t e r c h i l d guidance c l i n i c s were p a r t i a l l y modelled.  E i g h t years l a t e r ,  under the name o f the I n s t i t u t e f o r J u v e n i l e Research, the Chicago I n s t i t u t e was taken over by the s t a t e and extended to cover the wider f i e l d o f c h i l d guidance. Under t h i s broader p o l i c y an i n c r e a s i n g l y l a r g e number of cases were r e f e r r e d from o t h e r sources i n the community„  "Among  these were many from f a m i l y a g e n c i e s , c h i l d p l a c i n g a g e n c i e s , and agencies concerned w i t h h e a l t h , as w e l l as from the p u b l i c s c h o o l s  2 and from the p a r e n t s . "  While p a r e n t s comprised the s m a l l e s t p e r -  centage o f r e f e r r a l s a t t h i s time i t i s noteworthy  t h a t by 1934  they r e f e r r e d 25 p e r cent o f the cases, b e i n g second only t o schools w i t h 27 p e r c e n t .  T h i s was a l o g i c a l development  since  Stevenson, George & Smith, Geddes, C h i l d Guidance C l i n i c s . A Quarter Century o f Development, The Commonwealth Fund, New York, 1 9 3 ^ , P. 15  2  Stevenson, & Smith, I b i d . . p. 322  7 "under any c o n c e p t i o n of p s y c h i a t r y , parents are i n v o l v e d i n the treatment of c h i l d r e n f o r they i n i t i a t e the a c t i o n and c a r r y out  1  many of the t h e r a p e u t i c measures." The f i r s t c h i l d guidance c l i n i c s i n 1922  (so named) were s e t up  i n S t . L o u i s and N o r f o l k as demonstration u n i t s by the Nat-  i o n a l Committee f o r Mental Hygiene  and the Commonwealth Fund.  They  worked wholly through the c o u r t s but soon d i s c o v e r e d t h a t the most e f f e c t i v e p r e v e n t i v e work was misconduct  t o be done w i t h c h i l d r e n whose  had not y e t been accounted l e g a l d e l i n q u e n c y .  Later  c l i n i c s were t h e r e f o r e e s t a b l i s h e d i n c o n n e c t i o n w i t h h o s p i t a l s or s c h o o l s , and r e f e r r a l s were sought.from p a r e n t s , t e a c h e r s , and social  workers. C h i l d Guidance  c l i n i c i a n s early r e a l i z e d that parents  as w e l l as c h i l d r e n were t h e i r p a t i e n t s .  Stevenson and  Smith  1  write:  " I t has been r e c o g n i z e d from the e a r l y days of c h i l d guidance t h a t the c l o s e involvement of the c h i l d w i t h i t s p a r e n t s , and e s p e c i a l l y w i t h i t s mother, make treatment of the mother an almost 2 i n e v i t a b l e concomitant of treatment o f the c h i l d . 1 1  S e r v i c e t o parents assumed i n c r e a s i n g importance  and  'child' guid-  ance seemed a t one time to be near the p o i n t of l o s i n g i t s i d e n t i t y to 'parent' guidance. What e f f e c t d i d t h i s s h i f t i n emphasis have on the s o c i a l worker i n the c l i n i c ?  I t entailed a greater r e s p o n s i b i l i t y i n diag-  n o s t i c and treatment s k i l l s f o r most of the work w i t h parents l e f t to him.  The r a t i o n a l e of t h i s was  t h a t parents were a  was  critical  1 M o s l i n , Ralph S., D i f f e r e n t i a l Treatment In C h i l d Guidance Casework. U n i v e r s i t y of B r i t i s h Columbia MSW T h e s i s , 1952,p.5  2  Stevenson, George & Smith, Geddes, Op. C i t . . p.  91  8 p a r t of the environment of the c h i l d and the s o c i a l worker worked w i t h the environment.  V a r i o u s methods f o r the treatment  of par-  ents were slowly evolved, most o f them p r o c e e d i n g from a d e s i r e to a l t e r the p a r e n t s ' a t t i t u d e s i n order t h a t the p a t i e n t s would have a more f a v o u r a b l e emotional that some parents tions.  Others  environment.  I t was b e l i e v e d  could accept and p r o f i t from advice and sugges-  seemed t o need e d u c a t i o n - a k i n d of t u t o r i a l i n -  s t r u c t i o n r e g a r d i n g the emotional needs of c h i l d r e n i n which t h e i r own c h i l d r e n ' s motives and d e s i r e s were i n t e r p r e t e d to them. Again i t was h e l d t h a t c e r t a i n parents c o u l d b e s t b e n e f i t from g a i n i n g i n s i g h t i n t o t h e i r own p e r s o n a l problems.  I t was a l s o r e -  cognized t h a t some parents c o u l d be helped by what was c a l l e d " s u p p o r t i v e treatment,  which aimed n o t so much a t changing  them as  a t l e s s e n i n g t h e i r a n x i e t y about t h e i r c h i l d r e n o r d i v e r t i n g some 1 of t h e i r a t t e n t i o n . " The above d e s c r i p t i o n o f techniques  over-emphasizes the  s o c i a l worker's p l a n n i n g , n o t acknowledging t h a t , i n p r a c t i c e , she t r i e d to i n v o l v e the p a t i e n t i n h i s p l a n n i n g and t o adapt her methods to h i s needs.  I t was t h i s p r o c e s s , i n f a c t , which  f i e d t h a t parents c o u l d n o t be changed to o r d e r , nor c o u l d person p l a n f o r them how they should t h i n k and a c t toward  clarianother their  children. "The  p r e s e n t trend seems t o be toward a c l a r i f i c a t i o n  of casework and the k i n d o f h e l p i t can o f f e r , and of i t s d i s 2 t i n c t i o n from p s y c h i a t r y . " I n other words some c h i l d guidance 1  VJitmer, Helen, Op. C i t . . p . 3^7 2 Witmer, I b i d . , p . 3^8  9 c l i n i c s s t i l l p l a n the h a n d l i n g not  of a case i n terms of whether or  the a t t i t u d e s of the p a r e n t s need changing and,  i f so, what  methods can b e s t be employed to e f f e c t the d e s i r e d change. c l i n i c s s t a t e t h e i r f u n c t i o n more s p e c i f i c a l l y as c h i l d ance'  f  Other  'guid-  the s o c i a l worker p r o v i d i n g a h e l p i n g s i t u a t i o n i n which  the parent may  express h i s f e e l i n g s about h i s c h i l d and  mobilize  h i s c a p a c i t i e s f o r d e c i d i n g what he w i l l do about the problem. "This help  i s offered —  i n the b e l i e f t h a t the c h i l d w i l l b e n e f i t  i f h i s parents can become more comfortable i n t h e i r f e e l i n g s about 1 him." Regardless of emphasis ( t h a t i s , s t r i c t l y ance and/or p e r s o n a l i t y problems of the p a r e n t s ) , conception changed.  of the f u n c t i o n and The  the  worker today Is not  the a i d e but  guid-  original  r o l e of the s o c i a l worker  the p s y c h i a t r i s t i n a d i a g n o s t i c and  has  the c o l l e a g u e  of  treatment u n d e r t a k i n g t h a t  u s u a l l y i n v o l v e s work w i t h s e v e r a l people i n any The  'child'  one  case.  f o r e g o i n g d i s c u s s i o n has b r i e f l y surveyed the evo-  l u t i o n of the r o l e of s o c i a l workers i n c h i l d guidance i n r e l a t i o n to t h e i r treatment of c h i l d r e n and p a r e n t s .  As members of a p r o -  f e s s i o n s o c i a l workers must assume r e s p o n s i b i l i t y f o r the r e s u l t s , favourable  and  unfavourable, o f t h e i r c o n t r i b u t i o n s to the  n o s t i c t h i n k i n g and This w i l l  treatment recommendations of the c l i n i c  i n c l u d e a genuine concern w i t h the problem of  who  withdraw from treatment, and  and  s k i l l s i n an e f f o r t to combat the problem. 1  Witmer, I b i d . . p.  349  a continued  diagteam.  clients  r e f i n i n g of methods  10  Principles The e v o l u t i o n of the s o c i a l worker's r o l e i n c h i l d guidance was n o t , and i s not, i s o l a t e d of p r o f e s s i o n a l our  from the growth and change  S o c i a l Work as a whole.  theory and p r a c t i c e  With the development o f  have come working p r i n c i p l e s  upon which a l l s o c i a l work can be based.  and concepts  The b a s i c p h i l o s p h y of  s o c i a l work i s b e l i e f i n the worth of every i n d i v i d u a l ,  i n h i s pot-  e n t i a l f o r growth and change and i n h i s r i g h t to f i n d h i s most s a t i s f y i n g s o c i a l adjustment f o r h i m s e l f and the community. a l s o b e l i e v e t h a t the community  has r e s p o n s i b i l i t y  We  toward the i n 1  dividual  i n a s s i s t i n g him to make t h i s optimum adjustment.  compatibility  The  of t h i s p h i l o s o p h y and c h i l d guidance i s e v i d e n t .  The l a t t e r , by e x i s t i n g  to h e l p c h i l d r e n  h e a l t h y and happy r e l a t i o n s h i p s presupposes t h e i r p o t e n t i a l responsibility  and parents a t t a i n more  w i t h i n the f a m i l y and  community,  f o r growth and development.  Community  i s f o s t e r e d by c h i l d guidance c l i n i c s through edu-  c a t i o n a l programs which b o t h r e c o g n i z e the need f o r a p o s i t i v e munity a t t i t u d e  com-  toward mental h e a l t h p r e s e r v a t i o n and aim t o make  people aware of c l i n i c s e r v i c e s and the emotional needs o f While the above p r i n c i p l e r e l a t e s  children.  t o the broad f i e l d of  s o c i a l work as a whole, i t i s perhaps d e s i r a b l e to i n c l u d e a d d i t ional principles  which focus more d i r e c t l y on t h i s study i n terms  of the problem o f d i s c o n t i n u a t i o n i n c h i l d guidance.  Once such  concept i s t h a t a l l b e h a v i o u r has a purpose and a meaning.  This  purpose and meaning are f r e q u e n t l y n o t r e c o g n i z e d by the person and n o t wholly under h i s conscious c o n t r o l .  Thus, the c l i e n t  d i s c o n t i n u e s treatment i s prompted to t h i s d e c i s i o n _  who  by reasons of -  (  Quoted from P h i l o s o p h y , Concepts & P r i n c i p l e s o f Social Work, U n i v e r s i t y o f B r i t i s h Columbia School of S o c i a l Work, prepared by M. C u n l i f f e , H. Exner, A. Furness, and H. McCrae.  11 which he i s both aware and unaware.  S o c i a l workers must c o n t i n u a l l y  s t r i v e both t o understand these c a u s a t i v e their s k i l l s  f a c t o r s and to improve  i n h a n d l i n g them, i f t h e i r e f f o r t s t o e l i m i n a t e the  problem o f d i s c o n t i n u a t i o n a r e to meet w i t h any degree o f s u c c e s s . Another concept t o which S o c i a l Work adheres and which i s p e r t i n e n t to t h i s study i s the d e s i r a b i l i t y  t h a t as much as pos-  s i b l e o f the t o t a l person and h i s l i f e h i s t o r y be taken i n t o cons i d e r a t i o n t o e x p l a i n h i s behaviour.  T h i s reaches a h i g h l y  devel-  oped degree o f p r o f e s s i o n a l e x p r e s s i o n i n the team approach, ( t h e team c o n s i s t i n g o f p s y c h i a t r i s t , p s y c h o l o g i s t , n u r s e ) , o f c h i l d guidance c l i n i c s . vantage o f t h i s s p e c i a l i z e d approach study i n t h i s t h e s i s . group  s o c i a l worker, and  The w r i t e r w i l l have the-adi n the cases s e l e c t e d f o r  These cases have been s e l e c t e d from a l a r g e  i n which the c l i e n t s have d i s c o n t i n u e d  treatment.  I t i s not  b e l i e v e d t h a t d i s c o n t i n u a t i o n i s always due t o circumstances which develop a f t e r r e f e r r a l ; o f t e n , i t tends to r e s u l t i n response t o l o n g e s t a b l i s h e d p a t t e r n s which a r e c o n s t i t u e n t s total personality.  o f the c l i e n t ' s  Thus, t o a r r i v e a t an understanding o f why a  c l i e n t discontinues,  i t i s necessary to see him, as f a r as p o s s i b l e ,  In r e l a t i o n to h i s t o t a l l i f e s i t u a t i o n . Perhaps  the most h e l p f u l way i n which t o approach an  understanding of the c l i e n t i n h i s t o t a l l i f e  s i t u a t i o n i s to  study him i n r e l a t i o n to h i s i n t e r a c t i o n w i t h other members o f his  family.  ing  c h a r a c t e r i s t i c s has been i t s concern w i t h the w e l f a r e o f the  family.  I t Is r e c o g n i z e d t h a t one of casework*s d i s t i n g u i s h -  The c h i l d guidance f i e l d w i t h i t s continued concern w i t h  f a m i l i e s i n d i s t r e s s has been a major c o n t r i b u t o r t o the emergence  12 of"family-centered" lem  casework.  Again, t h i s i s r e l e v a n t to the prob-  of d i s c o n t i n u a t i o n because the i n t r a - f a m i l i a l components a f f e c t -  ing diagnosis  and  treatment w i l l a l s o be  operating  i n withdrawal  from treatment. The  goal of f a m i l y centered  casework represents  t u r n to the f o l d " f o r many s o c i a l workers.  a "re-  "Today, there  c r e a s i n g r e c o g n i t i o n t h a t the mental hygiene and  is in-  psychoanalytic  movements l e d many s o c i a l workers away from the concern w i t h f a m i l y which had been emphasized by Mary Richmond, toward a occupation  w i t h i n d i v i d u a l psychopathology and  the pre-  i n t r a - p s y c h i c pro-  1 blems."  However, Miss Richmond's b a s i c p r i n c i p l e t h a t the  i s the u n i t of^social d i a g n o s i s f r e s h today and has  and  treatment sounds p a r t i c u l a r l y  been an i n f l u e n c i n g f a c t o r i n the development  of concepts of f a m i l y d i a g n o s i s c h i l d guidance  family  and  treatment, n o t a b l y  i n the  field.  I d e a l l y , "family-centered"  casework i s "casework t h a t  i s based on an understanding of the needs of the f a m i l y as a u n i t , f o r the purpose of h e l p i n g f a m i l y members a t t a i n t h e i r b e s t sonal and  s o c i a l s a t i s f a c t i o n s , and  to h e l p improve the  per-  social  2  f u n c t i o n i n g of the f a m i l y group as a whole." ments of " f a m i l y - c e n t e r e d " haps shed new  casework and  Further r e f i n e -  family diagnosis w i l l  l i g h t on the problem of d i s c o n t i n u a t i o n to which  the i n t e r a c t i o n of the f a m i l y members as a whole has related.  The _  per-  i d e a , however, has  been suggested: "The  not  y e t been  nature  and  S i p o r i n , Max "Family-Centered Casework i n a P s y c h i a t r i c S e t t i n g " , S o c i a l Casework. A p r i l , 1956, p. 167. 2  Scherz, Frances H., "What i s Family-Centered Casework", S o c i a l Casework. V o l . XXXIV, 1953, PP. 3 ^ 3 - 9 .  13 q u a l i t y of the i n t e r a c t i o n between s i g n i f i c a n t members o f a fami l y are v i t a l f a c t o r s i n the p r o g n o s i s f o r any one of the members 1 s e e k i n g a more e f f e c t i v e p e r s o n a l or f a m i l y adjustment.  In  11  t h i s q u o t a t i o n the meaning of the word 'prognosis' might i n c l u d e those c l i e n t s w i t h an a b i l i t y to those w i t h a tendency  to continue i n treatment as opposed  to d i s c o n t i n u e b e f o r e treatment  can  reach a s a t i s f a c t o r y conclusion. The e f f o r t s of s o c i a l workers toward the development of a t r u e " f a m i l y - c e n t e r e d " casework are an i n d i c a t i o n of the matu r a t i o n of s o c i a l work. i t s development w i l l larly  Continued  e x p l o r a t i o n and d i s c o v e r y i n  sharpen our d i a g n o s t i c s k i l l s and,  i n the c h i l d guidance  setting, w i l l assist i n selecting  those treatment goals most conducive client-continuance.  particu-  to f a m i l y p a r t i c i p a t i o n  Perhaps one of the most s i g n i f i c a n t of  and these  goals i s to keep the c l i e n t i n treatment.. Some a t t e n t i o n w i l l now  be g i v e n to the agency which  c o n s t i t u t e s the s e t t i n g of t h i s study and from whose  treatment  s e r v i c e s the c l i e n t s i n q u e s t i o n withdrew. S e t t i n g o f the Study The h i s t o r y of the C h i l d Guidance Movement i n B r i t i s h 2  Columbia has been d i s c u s s e d i n d e t a i l i n e a r l i e r theses  to  1  Gomberg, M. Robert, & L e v i n s o n , Prances T., Diagnosis and Process i n Family C o u n s e l i n g . New York: F.S.A.A. 1951* P » 22 2  See Coyle, P h y l l i s , 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 , U n i v e r s i t y of B r i t i s h Columbia MSW T h e s i s , 1955 C l a r k , R i c h a r d , Care of the M e n t a l l y 111 i n B r i t i s h Columbia. U n i v e r s i t y of B r i t i s h Columbia MSW T h e s i s , 194?.  14 which the reader i s r e f e r r e d .  The s e t t i n g of t h i s study i s the  major u n i t o f the B r i t i s h Columbia  1  Clinics  P r o v i n c i a l C h i l d Guidance  which i s l o c a t e d i n North Burnaby.  The C l i n i c i s a com-  munity agency i n which s p e c i a l i z e d p r o f e s s i o n s combine t h e i r knowledge and s k i l l and attempt  to employ the r e s o u r c e s of the  community t o meet the problems o f c h i l d r e n who a r e p o o r l y a d j u s t e d to t h e i r environment team attempts  and have u n s a t i s f i e d i n n e r needs . -  The C l i n i c  t o study the c h i l d as he i s a t r e f e r r a l and i n h i s  p r e s e n t environment;  to g e t the f a m i l y and community  interested  i n understanding the behaviour o f c h i l d h o o d and the b a s i c needs of c h i l d r e n ; and to t r e a t the p a r t i c u l a r p a t i e n t a c c o r d i n g t o h i s needs. The purpose  o f the C l i n i c i s t o d e t e c t and t r e a t  child-  ren's d i f f i c u l t i e s a t a stage when a c t u a l h e l p i n the home and the community i s s t i l l p o s s i b l e and when community r e s o u r c e s - educ a t i o n a l , s o c i a l , and medical can be used most e f f e c t i v e l y . The c o n t r i b u t i o n o f the s o c i a l worker i s to e x p l o r e w i t h the parents and c h i l d  the nature of the problem  them f i n d methods to d e a l w i t h i t .  and t o h e l p  The p s y c h o l o g i s t s t u d i e s the  c h i l d through t e s t s o f i n t e l l i g e n c e , a b i l i t y ,  i n t e r e s t s , and p e r -  s o n a l i t y , and may g i v e remedial h e l p of v a r i o u s k i n d s .  The psy-  c h i a t r i s t ' s c o n t r i b u t i o n i s i n the area of d i a g n o s i s and treatment of u n d e r l y i n g emotional problems and, w i t h the nurse, he i s r e 2 s p o n s i b l e f o r the medical aspects o f the problem. 1  H e r e a f t e r , 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 North Burnaby, B.C. w i l l be c a l l e d " C l i n i c " . 2 The New Westminster " B r i t i s h Columbian", a r t i c l e by Dr. U. P. Byrne, January 1 1 , 1 9 5 6 .  1  5  Functions The p r i m a r y and t r e a t m e n t  f u n c t i o n of the C l i n i c i s t h a t o f  of c h i l d r e n who  have p r o b l e m s .  study  I n a d d i t i o n to t h i s  b r o a d f u n c t i o n the C l i n i c has r e s p o n s i b i l i t y i n : 1.  O r i e n t a t i o n of i n d i v i d u a l s such as n u r s e s ,  s o c i a l workers,  d o c t o r s , t e a c h e r s , and mental h e a l t h c o - o r d i n a t o r s who  are  inter-  e s t e d i n the work o f the C l i n i c ' a n d i n l e a r n i n g about mental health principles.  The  C l i n i c a l s o takes r e s p o n s i b i l i t y f o r the  o r i e n t a t i o n of m e d i c a l , n u r s i n g , p s y c h o l o g i c a l , t e a c h i n g , and  soc-  i a l work s t u d e n t s . 2.  Community E d u c a t i o n . Through such media as l e c t u r e s , t a l k s ,  f i l m s , and case p r e s e n t a t i o n s the C l i n i c s t a f f c a r r y out a f u n c t i o n of p r o m o t i n g mental h e a l t h p r i n c i p l e s w i t h s u c h groups as P a r e n t - T e a c h e r A s s o c i a t i o n s , p a r e n t ' s groups, s e r v i c e "clubs, and institutes. '3.  P r o f e s s i o n a l Education.  At present, C l i n i c s t a f f give  lect-  u r e s or case p r e s e n t a t i o n s t o s t u d e n t s groups a t the U n i v e r s i t y of B r i t i s h Columbia, s c h o o l s o f e d u c a t i o n , m e d i c i n e , and n u r s i n g .  s o c i a l work,  C l i n i c s t a f f a l s o g i v e l e c t u r e s as w e l l as o r i e n -  t a t i o n to a f f i l i a t e n u r s e s from v a r i o u s c i t y h o s p i t a l s . 4.  Student P l a c e m e n t s .  placements f o r 4 - 8 and 1 5.  At present  the C l i n i c o f f e r s s t u d e n t  s o c i a l workers, 3 p s y c h o l o g i s t s - i n - t r a i n i n g ,  psychiatrist-in-training.  Community O r g a n i z a t i o n .  C l i n i c s t a f f p a r t i c i p a t e i n other  agency committees concerned w i t h the development of s e r v i e e s  and  a l s o p a r t i c i p a t e i n e x e c u t i v e or a d v i s o r y boards of o t h e r groups such as the Canadian N a t i o n a l I n s t i t u t e f o r the B l i n d ;  Cerebral  P a l s y Committee of the C h i l d r e n ' s H o s p i t a l ; C h i l d r e n ' s A i d  16 S o c i e t y of Vancouver (Family Children's Registry  and  C h i l d Care Committee); C r i p p l e d  (Medical Advisory  P a n e l ) ; Greater  Vancouver  Health League; U n i v e r s i t y of B r i t i s h Columbia School of S o c i a l Work; Advisory 6.  Committee on Research, and  Research P a r t i c i p a t i o n .  e r a t i o n a l r e s e a r c h along v i c e s , and research  The  C l i n i c at present  such l i n e s as case flow,  q u a l i t y of s e r v i c e s .  conducted by  others.  The  conducts extent  op-  of s e r -  Clinic staff participates in  the U n i v e r s i t y of B r i t i s h Columbia Neuro-  l o g i c a l Research Department, s o c i a l work students,  psychology s t u -  dents, Crease C l i n i c , Department of Neurology, and  the  Chest and Types of 1.  Community  Council. Services  Diagnostic.  The  C l i n i c o f f e r s a d i a g n o s t i c s e r v i c e to c h i l d r e n  up to 18 years to s o c i a l and h e a l t h agencies working w i t h him  and  his  ex-  f a m i l y or g u a r d i a n s . 1  amination for  This service involves f u l l  of the c h i l d , f o l l o w e d by f o r m u l a t i o n  clinical  of recommendations  treatment, which i s p a r t of the c o n t i n u i n g r e s p o n s i b i l i t y of  the agency p r e s e n t i n g  the  case.  "Re-examination" i s e s s e n t i a l l y  the same as the d i a g n o s t i c s e r v i c e and  i s a v a i l a b l e where repeated  or supplementary examination i s i n d i c a t e d , 2.  Consultative.  L i k e the d i a g n o s t i c s e r v i c e , the c o n s u l t a t i v e  service involves d i s c u s s i o n of diagnosis ment c o n s i d e r a t i o n s ) the case and  (and may  include t r e a t -  a t a conference between the agency  the C l i n i c team, where the agency has  s p o n s i b i l i t y f o r the case.  Unlike  ever, such c o n s u l t a t i o n i s not  presenting  continuing  re-  the d i a g n o s t i c s e r v i c e , how-  immediately preceded by  clinical  _ in  A d e s c r i p t i o n of a " f u l l c l i n i c a l the c o n c l u d i n g paragraph, page 14  examination" i s g i v e n  17 examination,  though the p a t i e n t under d i s c u s s i o n may or may n o t  have "been examined on a p r e v i o u s occasion,, 3.  Direct Service,  (a)  The C l i n i c o f f e r s d i r e c t s e r v i c e s t o  c h i l d r e n up t o 18 years of age, and t h e i r p a r e n t s , on the a p p l i c a t i o n of the f a m i l y , or on r e f e r r a l of p r o f e s s i o n a l or  organizations.  individuals  This service involves f u l l c l i n i c a l  Treatment i s the r e s p o n s i b i l i t y o f the C l i n i c a l o n e , e r a t i v e or J o i n t S e r v i c e occurs when simultaneous  examination. (b)  Co-op-  s e r v i c e s o f the  C l i n i c and another r e s o u r c e a r e i n d i c a t e d , and may i n v o l v e j o i n t d i a g n o s t i c and treatment  services.  Responsibility i s carried  j o i n t l y , the C l i n i c or the other agency b e i n g determined  as the  major one by mutual agreement. The C l i n i c i s prepared to d e a l w i t h many types of p r o blems.  These i n c l u d e almost any behaviour which i s d i s t u r b i n g t o  the parent or c h i l d and which, i f continued, might handicap the c h i l d ' s g e n e r a l adjustment  in life.  They may be such outward  problems as l y i n g , s t e a l i n g , c h r o n i c e n u r e s i s , truancy, and defiance.  A l s o , there a r e problems o f withdrawal  e x c e s s i v e shyness,  as manifested i n  f e a r o f attempting new g o a l s , s e t t i n g too h i g h  standards, overdependency on p a r e n t s , and r e l u c t a n c e t o mix w i t h other c h i l d r e n . some degree. beyond  A l l c h i l d r e n may show some o f these symptoms t o  Cause f o r concern i s when t h e i r behaviour  swings  'normal' l i m i t s . There i s a l s o the problem o f the r e t a r d e d c h i l d .  C l i n i c aims to determine  the extent of h i s d e f i c i e n c y and h e l p s  the parent t o d e a l w i t h t h i s slow c h i l d so t h a t he w i l l to  The  develop  the maximum of h i s own a b i l i t y .  Diagnostic Evaluation Period In  t h i s study o f c l i e n t s who have d i s c o n t i n u e d treatment  18 the w r i t e r w i l l  examine o n l y  cases I n which t h e C l i n i c  team a s -  1 si^med f u l l be  responsibility  studied w i l l  i n treatment s e r v i c e s .  The c a s e s t o  have completed t h e d i a g n o s t i c e v a l u a t i o n  stage  o f t r e a t m e n t , and have a c c e p t e d t h e C l i n i c recommendations forjcont i n u e d casework s e r v i c e s w h i c h would be a v a i l a b l e a f t e r the w a i t ing-period. will  Some d i s c u s s i o n o f t h e d i a g n o s t i c e v a l u a t i o n  period  be b e n e f i c i a l t o t h e r e a d e r ' s u n d e r s t a n d i n g o f t h e s e r v i c e s  r e c e i v e d b y t h e s e c l i e n t s up t o t h e p o i n t o f t h e i r d i s c o n t i n uation. A t r e f e r r a l , w h i c h i s u s u a l l y made b y t h e p a r e n t , t h e duty worker obtains  a statement of the problem.  to a worker o f the Intake load permits.  and B r i e f S e r v i c e s  T h i s may i n v o l v e a w a i t  worker performs the p r e l i m i n a r y  The c a s e i s p a s s e d  S e c t i o n when h i s  o f up t o t h r e e  case-  months.  This  i n t a k e s t u d y , u s u a l l y one o r two  i n t e r v i e w s w i t h t h e p a r e n t s i n as many w e e k s , a f t e r w h i c h t h e c a s e i s presented a t an intake conference.  At this point a decision  i s made w h e t h e r o r n o t t h e c a s e c a n b e n e f i t f r o m C l i n i c If  i t can, i t proceeds through the d i a g n o s t i c e v a l u a t i o n  A planning on  conference provides  t h e needs o f e a c h c a s e .  an o p p o r t u n i t y  At this  a f u t u r e d a t e when t h e p s y c h o l o g i s t the p s y c h i a t r i s t w i l l the  services. period.  for planning  based  time appointments a r e s e t f o r will  s e e t h e c h i l d a n d when  i n t e r v i e w t h e p a r e n t s and c h i l d .  i n t e r i m p e r i o d the s o c i a l worker w i l l  have r e g u l a r  During interviews  w i t h t h e p a r e n t s e x p l o r i n g w i t h them t h e n a t u r e o f t h e p r o b l e m and  t h e i r f e e l i n g s and a t t i t u d e s around i t .  He a l s o p r e p a r e s a  s o c i a l h i s t o r y which i s completed by the time t h e p s y c h i a t r i s t  1  Refer to d e s c r i p t i o n of "Direct Service  ( a ) " , p . 17  19 has h i s f i r s t i n t e r v i e w w i t h the f a m i l y .  A diagnostic  confer-  ence Is h e l d f o l l o w i n g t h i s c l i n i c a l examination of the  child.  Here, the m u l t i - d i s c i p l i n e d approach i s employed to a r r i v e a t a p s y c h o s o c i a l d i a g n o s i s of and  treatment p l a n f o r the c h i l d based,  t o as g r e a t a degree as p o s s i b l e , on h i s t o t a l needs i n r e l a t i o n to h i s t o t a l environment.  Treatment may  c o n s i s t of v a r i o u s  commendations i n c l u d i n g b r i e f or c o n t i n u i n g s e r v i c e s .  The  means treatment of r e l a t i v e l y g r e a t e r l e n g t h , u s u a l l y from months to s e v e r a l years  i n some c a s e s .  A great  of the case and  time a v a i l a b l e among s t a f f of other d i s c i p l i n e s to g i v e T h i s marks the end  latter two  In p r a c t i c e , most of these  s e r v i c e s are c u r r e n t l y g i v e n by s o c i a l workers. however, depends on the a p p r o p r i a t e n e s s  re-  deal, on  the  treatment.  of the d i a g n o s t i c e v a l u a t i o n p e r i o d which, as  noted, w i l l have been completed by a l l the c l i e n t s forming s u b j e c t matter of t h i s  the  study.  S o c i a l S e r v i c e Department For c l a r i f i c a t i o n purposes a b r i e f mention o f  the  C l i n i c ' s s o c i a l s e r v i c e department might be h e l p f u l to the I t Is d i v i d e d i n t o two main s e c t i o n s as f a r as d i r e c t are concerned; the Intake and B r i e f S e r v i c e s and Service sections.  reader.  services  the Continued  Cases which are recommended a t d i a g n o s t i c con-  f e r e n c e f o r c o n t i n u i n g casework s e r v i c e s are t r a n s f e r r e d from I n take to the Continued S e r v i c e S e c t i o n . are not considered t a b l e by  While r o u t i n e t r a n s f e r s  d e s i r a b l e i n themselves, they are made i n e v i -  the s e c t l o n a l i z i n g of the s o c i a l s e r v i c e department  T h i s s t r u c t u r i n g was Clinic's program. i n the program was  One  staff.  made to adapt to o v e r a l l developments i n the of the s e v e r a l f a c t o r s l e a d i n g t o changes  t h a t the demand' f o r s e r v i c e s i n c r e a s e d out  of  p r o p o r t i o n to the number of s t a f f a v a i l a b l e to g i v e these s e r v i c e s .  20 T h i s r e s u l t e d i n the development o f a w a i t i n g p e r i o d f o r s e r v i c e s . P r i o r to the c r e a t i o n o f the two s e c t i o n s i n 1 9 5 4 , app l i c a t i o n s were r e c e i v e d by duty workers, f o l l o w i n g which each case was assigned all  t o a s o c i a l worker, who would be r e s p o n s i b l e f o r  s o c i a l s e r v i c e s r e q u i r e d by the case u n t i l i t s t e r m i n a t i o n .  As the volume o f c l i e n t s i n c r e a s e d a s u b s t a n t i a l w a i t i n g developed between a p p l i c a t i o n and assignment. undesirable  T h i s was  period considered  because some cases needed a t t e n t i o n immediately: r e -  f e r r a l to other agencies c o u l d be more a c c u r a t e l y determined i f f u r t h e r e x p l o r a t i o n was done w h i l e other  cases seemed more amen-  able t o treatment a t the p o i n t o f i n i t i a l a p p l i c a t i o n . s e c t i o n was t h e r e f o r e c r e a t e d provide uninterrupted  The Intake  to augment the c l i n i c ' s e f f o r t s t o  s e r v i c e from a p p l i c a t i o n t o the end o f the  d i a g n o s t i c p e r i o d , and treatment s e r v i c e o f a b r i e f  duration.  Thus, the w a i t i n g p e r i o d , o r g i n a l l y a t the o u t s e t , was moved p r o g r e s s i v e l y forward u n t i l i t remained s t a t i o n a r y a t the p o i n t i n g the d i a g n o s t i c conference and p r i o r t o continued  follow-  service.  T h i s meant t h a t only cases recommended f o r l o n g term treatment (about f i f t e e n per cent o f a l l a p p l i c a t i o n s ) were o b l i g e d t o wait,.. The  l e n g t h o f the w a i t i n g p e r i o d v a r i e s from v i r t u a l l y none t o  one  and one-half  y e a r s , depending p a r t l y on s t a f f numbers and on  p r i o r i t y o f cases. The another 'wait  Intake c a s e l o a d 1  has i n c r e a s e d  has developed a t the o u t s e t .  t o the p o i n t  that  P r i o r i t y of assign-  ment i s e s s e n t i a l l y c h r o n o l o g i c a l but i s a l s o g i v e n on the b a s i s of problem and o f the i n t a k e worker's e v a l u a t i o n .  I t i s the i n -  take worker's r e s p o n s i b i l i t y t o prepare the c l i e n t f o r the w a i t i n g p e r i o d and f o r reassignment t o the continued  s e r v i c e caseworker.  21  The c l i e n t should a l s o be p s y c h o l o g i c a l l y prepared f o r the t r e a t ment, i n c l u d i n g the reasons f o r i t . Focus of the  Study  The purpose  of t h i s study w i l l be to e x p l o r e the  of c l i e n t - d i s c o n t i n u a t i o n from treatment a t the C l i n i c . i t may  problem  Although  occur a t v a r i o u s p o i n t s i n a case withdrawal or d i s c o n t i n -  u a t i o n i n t h i s study i s d e f i n e d as the p a r e n t s ' severeance of cont a c t w i t h the C l i n i c a t the p o i n t when continued s e r v i c e s are o f f e r e d f o l l o w i n g the d i a g n o s t i c e v a l u a t i o n and w a i t i n g - p e r i o d s . "Treatment"  i s d e f i n e d as b e g i n n i n g a t the f i r s t  c o n t a c t between  the c l i e n t and the C l i n i c . A d m i n i s t r a t i v e i m p l i c a t i o n s of the problem w i l l be  dis-  cussed, I n c l u d i n g an e v a l u a t i o n of the w a i t i n g - p e r i o d and some sugg e s t i o n s as t o how n i f i c a n t way.  i t might be u t i l i z e d i n a t h e r a p e u t i c a l l y  sig-  Reference w i l l a l s o be made t o the importance  that  C l i n i c workers r e c o g n i z e r e s i s t i v e c l i e n t s a t the b e g i n n i n g i f the problem  of withdrawal  i s to be e f f e c t i v e l y  handled.  The study w i l l a l s o h o p e f u l l y e l u c i d a t e h y p o t h e t i c a l " i n d i c a t o r s " which, when a p p l i e d to f u t u r e c a s e s , might have  prognos-  t i c v a l u e i n d e t e r m i n i n g which of those cases are l i k e l y to w i t h draw.  Once a l e r t e d to t h i s danger, the worker can prepare f o r i t ,  a d a p t i n g h i s s k i l l s t o h e l p a p a r t i c u l a r c l i e n t continue treatment t o t e r m i n a t i o n .  through  T h i s i s a step toward a more e f f e c t i v e  refinement of treatment goals and a more a c c u r a t e p r e d i c t i o n of treatability.  The g o a l of a l l r e s e a r c h i s u l t i m a t e l y  prediction,  and an e x p l o r a t o r y study such as t h i s i s an Imperative p r e l u d e to a more r e f i n e d method of p r e d i c t i o n .  2 2  In Chapter Two  the problem of d i s c o n t i n u a t i o n w i l l  examined i n f i v e case s t u d i e s and f i v e follow-up i n t e r v i e w s ducted by the w r i t e r . will facilitate erates  I t i s hoped t h a t t h i s  limited  be con-  exploration  a g r e a t e r understanding of the problem as i t op-  In withdrawal cases as a whole  0  CHAPTER I I  The Reasons F o r D i s c o n t i n u a t i o n  A t o t a l o f f o r t y c a s e s w e r e e x a m i n e d a s p o t e n t i a l material  f o r t h i s study.  These were c a s e s i n w h i c h p a r e n t s  and c h i l d -  r e n w i t h d r e w f r o m t r e a t m e n t d u r i n g t h e p e r i o d J a n u a r y 1,  1956*  December 31#  points of withdrawal  1954 t o  Many o f t h e c a s e s w e r e e l i m i n a t e d b e c a u s e differed.  O t h e r s were d i s r e g a r d e d  the r e c o r d i n g o f the i n t e r v i e w s d u r i n g t h e d i a g n o s t i c  their  because evaluation  p e r i o d was n o t s u f f i c i e n t l y d e t a i l e d t o i l l u m i n a t e t h e p r o b l e m areas which a r e under s c r u t i n y by t h e w r i t e r .  To h a v e u s e d t h e  l a t t e r w o u l d h a v e e n t a i l e d s o many a s s u m p t i o n s o n t h e p a r t o f t h e w r i t e r a s t o make t h e s t u d y  invalid.  Many o f t h e f o r t y c a s e s s c a n n e d d i d n o t s t a t e p r e c i s e l y t h a t d i s c o n t i n u a t i o n had o c c u r r e d  contrary  o t h e r w o r d s , n o a s s e s s m e n t was r e c o r d e d to continue  treatment.  to expectation.  of the client's  capacity  A l a r g e percentage i n d i c a t e d t h a t t h e work-  ers d i dn o t v e r b a l l y suggest t o the c l i e n t s the value uation.  In  I t i s recognized,  o f course,  of contin-  that the recording  i s often  summarized and does n o t i n c l u d e t h e s u b t l e b u t m e a n i n g f u l o f t h e c l i e n t s ' r e s p o n s e s when c o n t a c t  f o r continued  content  s e r v i c e s was  made. T h e r e was a v a r i e t y o f r e s p o n s e s f r o m t h e c l i e n t s suggestion  of  a follow-up  a b l e when t h e f i r s t  i n t e r v i e w by t h e w r i t e r :  telephone contact  to the  two were a g r e e -  was c o m p l e t e d ; two w e r e q u i t e  24 r e s i s t a n t and i t was  necessary to c a l l  them three times each over  an I n t e r v a l of t h r e e weeks; one mother requested t h a t a second  call  be made so t h a t she might rearrange her schedule i n o r d e r to accommodate the i n t e r v i e w .  The w r i t e r thought i t worthwhile  pend t h i s amount of time a r r a n g i n g the i n t e r v i e w s because, a l l p o s s i b l e , i t was  to exi f at  d e s i r a b l e to i n t e r v i e w those c l i e n t s whose  case r e c o r d s were most s u i t e d to the study. Methodology The r e s e a r c h methodology used i n t h i s study i n c l u d e d summaries of f i v e cases i n which parents withdrew from treatment a t the C l i n i c . of  The s e l e c t i o n o f the f i v e cases was based on r i c h n e s s  r e c o r d i n g and on a c c e s s i b i l i t y of the c l i e n t s f o r f o l l o w - u p i n -  terviews.  The purpose of the case summaries was  to e l u c i d a t e  and  i d e n t i f y f a c t o r s or i n d i c a t o r s i n the d i a g n o s t i c study i n t e r v i e w s which might c o n s t i t u t e the b a s i s o f a p r e d i c t i o n o f withdrawal treatment.  T h i s was  from  accomplished by u s i n g a schedule focused on  the parents* r e l a t i o n s h i p s w i t h the C l i n i c , t h e i r responses t o and c o n c e p t i o n of the c h i l d ' s problem, background  and s i g n i f i c a n t events i n t h e i r  which seemed r e l e v a n t to the  problem.  F i v e f o l l o w - u p i n t e r v i e w s were h e l d - f o u r w i t h mothers, and one j o i n t i n t e r v i e w w i t h a mother and f a t h e r . demonstrate  The i n t e r v i e w s  the c l i e n t s * v e r b a l i z e d reasons f o r d i s c o n t i n u a t i o n .  The r e s u l t s were achieved by means of a schedule upon which the i n terviews were s t r u c t u r e d and which focused on the a t t i t u d e s o f the c l i e n t s to t h e i r t o t a l C l i n i c experience.  T h i s was  r e l a t e d to  whether or not the C l i n i c had, i n t h e i r o p i n i o n , been h e l p f u l , t h e i r f e e l i n g s about the w a i t i n g - p e r i o d , and t h e i r suggestions as to how  the C l i n i c s e r v i c e s might be more h e l p f u l .  25 The cases In t h i s study are not Intended to r e p r e s e n t a c r o s s - s e c t i o n of a l l cases which have withdrawn from a t the C l i n i c .  I t i s suggested, however, t h a t a s s o c i a t i o n s de-  t e c t e d i n these f i v e cases may others.  treatment  and probably w i l l be found a l s o i n  T h i s i s based not on t h e i r s t a t i s t i c a l r e p r e s e n t a t i v e n e s s  but on the f a c t t h a t the a s s o c i a t i o n s d i s c o v e r e d are c o n s i s t e n t w i t h p r e - e x i s t e n t b o d i e s of theory which i t might be assumed w i l l apply i n comparable measure to the cases not s t u d i e d . study i s r e q u i r e d to determine  the v a l i d i t y of t h i s  Further  assumption.  In t h i s chapter the reader i s i n t r o d u c e d to the cases used i n the study. lowing sequence:  Each case i s presented s e p a r a t e l y i n the  fol-  case summary and I n t e r v i e w , f o l l o w e d by a d i s c u s -  s i o n o f the i m p l i c a t i o n s of the i n t e r v i e w f o r the study. chapter concludes w i t h an assessment  The  of the h e l p r e c e i v e d by  the  c l i e n t s as a r e s u l t of t h e i r C l i n i c c o n t a c t . The focus i n Chapter Three w i l l be on the e l u c i d a t i o n and i l l u s t r a t i o n o f " i n d i c a t o r s " or p a t t e r n s which are common t o the cases as a whole and which, i f a p p l i e d to a d d i t i o n a l cases, might serve  t o p r e d i c t withdrawal from treatment.  of the chapter w i l l  The l a s t  i n c l u d e a d i s c u s s i o n of the c l i e n t s  1  half  reasons  f o r withdrawal from treatment, based on the f i v e i n t e r v i e w s .  26 Case No.  1 - B i l l y ANDERSON  Mrs. Anderson, a t the s u g g e s t i o n of the f a m i l y d o c t o r , r e f e r r e d her e i g h t year o l d son B i l l y f o r C l i n i c h e l p . She des c r i b e d him as a h i g h strung, nervous c h i l d who r o l l e d h i s eyes, c r i e d e x c e s s i v e l y , and acted out by l y i n g and s t e a l i n g . I t was e v i d e n t from the b e g i n n i n g t h a t B i l l y was r e a c t i n g to extreme ove r t r e j e c t i o n by h i s mother. She a t t a c k e d B i l l y v i c i o u s l y d u r i n g her e i g h t i n t e r v i e w s w i t h the s o c i a l worker. Such d e n u n c i a t i o n s as "he's been a m i s e r a b l e k i d s i n c e the day he was born," "I c e r t a i n l y d i d n ' t p l a n on having a boy", and " i f I'd g i v e n i n to him I would have k i l l e d him," i l l u s t r a t e her i n t e n s e h o s t i l i t y . G u i l t f e e l i n g s would seem to have prompted the r e f e r r a l , f o r mother s a i d , "I sometimes wonder and worry about what I am d o i n g to B i l l y . " Her understanding of the s i t u a t i o n remained a t t h i s i n t e l l e c t u a l , s u p e r f i c i a l l e v e l without the m o t i v a t i o n r e q u i r e d to Involve h e r s e l f In the examina t i o n of her own f e e l i n g s so t h a t her behaviour toward B i l l y might be m o d i f i e d . Father's r o l e In the house was a subordinate one ; He admitted spending l i t t l e time w i t h h i s f a m i l y owing to p r e s s u r e s o f work and community a c t i v i t i e s . He acquiesced i n h i s w i f e ' s assuming the r o l e of d i s c i p l i n a r i a n although he sometimes " f e l t " she was too s t r i c t . He thought h i s wife exaggerated B i l l y ' s problems but r e a l i z e d h i s almost detached p o s i t i o n . t  aged f o u r .  Both p a r e n t s spoke f o n d l y of the younger s i b l i n g , Teddy, He was d e s c r i b e d as a p p e a l i n g and l o v e a b l e .  Mrs. Anderson's c h i l d h o o d was marked by an i n t e n s e , unr e s o l v e d hatred f o r her f a t h e r . She wondered f l e e t i n g l y a t one p o i n t i f she were d e s t i n e d to t r e a t B i l l y i n a manner which r e hearsed her f a t h e r ' s treatment of h e r s e l f and.Jher s i b l i n g s . Part i c u l a r l y v i v i d i n her memory was her f a t h e r ' s c r u e l a t t i t u d e t o ward her only b r o t h e r , (her f a v o u r i t e s i b l i n g ) . I t would appear, t h e r e f o r e , t h a t Mrs. Anderson's treatment o f B i l l y was r e l a t e d to her f e e l i n g s about her f a t h e r . T h i s becomes more c o n c l u s i v e when we d i s c o v e r t h a t Mrs. Anderson's f a t h e r , " s t r a n g e l y enough, thought the world of B i l l y . " With the e x c e p t i o n of the two i n s t a n c e s a l ready c i t e d , mother saw B i l l y ' s behaviour as a c a l c u l a t e d a t t a c k upon h e r s e l f , separate and a p a r t from her own p e r s o n a l i t y , and cont r o l l a b l e only by a g g r e s s i v e , p u n i t i v e punishment. Both p a r e n t s i n d i c a t e d acceptance but l i t t l e r e a l unders t a n d i n g of the d i a g n o s t i c e v a l u a t i o n p e r i o d . Father was a co-ope r a t i v e , unenthused p a r t i c i p a n t . I t would seem t h a t mother made the d e c i s i o n s and he went a l o n g to keep the peace. Mrs. Anderson h e r s e l f r e l a t e d p o s i t i v e l y to the worker but used the r e l a t i o n " s h i p s o l e l y to v e r b a l i z e her h o s t i l i t y toward b o t h B i l l y and her father. Her a f f e c t was markedly a g g r e s s i v e and n e g a t i v e , w i t h some d i s t r e s s around her g u i l t f e e l i n g s . She missed two a p p o i n t ments without e x p l a n a t i o n . Although the w r i t e r noted t h a t the f i r s t c a n c e l l a t i o n f o l l o w e d the Interview i n which Mrs. Anderson had a "glimmer" t h a t she might be a c t i n g l i k e her f a t h e r .  27 She a s k e d t h e w o r k e r f o r h e l p i n I n t e r p r e t i n g t h e C l i n i c t o B i l l y : " I d o n ' t s e e how I c a n t e l l h i m t h a t t h e C l i n i c w i l l h e l p b e c a u s e I d o n ' t t h i n k he f e e l s he i s u n h a p p y . " She was una b l e t o f o l l o w the worker's s u g g e s t i o n s . Mr. A n d e r s o n f i n a l l y h a d t o assume r e s p o n s i b i l i t y f o r d i s c u s s i n g t h e C l i n i c w i t h B i l l y . Mrs. Anderson b r o u g h t B i l l y f o r h i s f i r s t C l i n i c a p p o i n t ment e x p l a i n i n g t o h i m t h a t he "was g o i n g t o meet a new friend." A f t e r he had gone w i t h t h e p s y c h o l o g i s t she a g a i n d e s c r i b e d h i s m i s e r a b l e b e h a v i o u r t o make s u r e t h e C l i n i c p e o p l e w o u l d n o t be f o o l e d by h i s " a c t " t o d a y . A t d i a g n o s t i c c o n f e r e n c e B i l l y was d e s c r i b e d as r e a c t i n g to h i s p a r e n t s ' ( l a r g e l y m o t h e r ' s ) c o n t r o l s and r e j e c t i o n . Cont i n u e d c a s e w o r k s e r v i c e s w e r e recommended f o r m o t h e r a n d B i l l y w i t h l e s s frequent contact w i t h f a t h e r . Mother r e q u i r e d i n t e r p r e t a t i o n o f B i l l y ' s n e e d s , c h i l d b e h a v i o u r , and a l s o needed h e l p t o r e c o g n i z e and u n d e r s t a n d h e r own h o s t i l i t y . Further exploration was recommended I n t o M o t h e r ' s r e l a t i o n s h i p s w i t h h e r own parents and b r o t h e r . F a t h e r was t o be e n c o u r a g e d t o g i v e more a t t e n t i o n to B i l l y . The team members c o n s i d e r e d t h e p r o g n o s i s t o be g o o d l C l i n i c f i n d i n g s were i n t e r p r e t e d to the Andersons sepa r a t e l y , f i r s t w i t h f a t h e r and t h e n w i t h mother. L i t t l e i s r e c o r d e d o f Mr. A n d e r s o n ' s comments e x c e p t t h a t he a p p r e c i a t e d t h e h e l p r e c e i v e d and w o u l d t r y t o g i v e B i l l y more a t t e n t i o n . M r s . A n d e r s o n was r e s t r a i n e d and a n x i o u s d u r i n g h e r l a s t interview. She a s k e d w h a t was meant by " t r e a t m e n t " , and expressed d o u b t t h a t she c o u l d e v e r b e h a v e d i f f e r e n t l y w i t h B i l l y . The w a i t i n g p e r i o d was e x p l a i n e d a s was t h e c h a n g e i n w o r k e r s . M r s . A n d e r s o n ' s r e a c t i o n s t o t h i s , i f any, are n o t r e c o r d e d . A tentative a p p o i n t m e n t was a r r a n g e d f o r a n o t h e r i n t e r v i e w p r i o r t o t h e w a i t ing period. She d i d n o t seem a n x i o u s f o r t h i s a n d d i d n o t k e e p the appointment. M r s . A n d e r s o n r e f u s e d t o c o n t i n u e t r e a t m e n t when t h e C l i n i c worker c a l l e d her a f t e r a w a i t i n g - p e r i o d of t h i r t e e n months. Telephone  Contact  I c a l l e d Mrs. A n d e r s o n t h i s morning. I s a i d I was c a l l i n g i n r e s p e c t t o t h e l e t t e r s h e had r e c e i v e d e a r l i e r t h i s week f r o m t h e D i r e c t o r . She s a i d , "Oh y e s . " I w o n d e r e d i f she f e l t s h e w o u l d be a b l e t o h a v e a n I n t e r v i e w w i t h me a s t h e l e t t e r had s u g gested. W i t h some h e s i t a t i o n she r e p l i e d , " t h a t a l l d e p e n d s on w h e t h e r o r n o t I h a v e t o come o u t t o B u r n a b y . " I assured her that we h a d n o t c o n s i d e r e d t h i s a n d t h a t I w o u l d be p l e a s e d t o come around to the house i f t h a t were c o n v e n i e n t . She t h o u g h t t h a t w o u l d be f i n e b u t she r e a l l y d i d n ' t t h i n k s h e ' d be a b l e t o h e l p me as t h e o n l y p e r s o n she h a d s e e n a t t h e C l i n i c was M r s . J . I c o u l d u n d e r s t a n d t h a t a n d knew t h e r e may be t h i n g s I w o u l d a s k t h a t she w o u l d f e e l she was u n a b l e t o a n s w e r . T h e r e w o u l d be no obl i g a t i o n i n v o l v e d and we w o u l d j u s t d i s c u s s t h i n g s t h a t she f e l t she c o u l d i n r e l a t i o n t o w h a t she remembered o f h e r C l i n i c c o n t a c t . She seemed t o r e l a x somewhat and s a i d , " i n t h a t c a s e y o u c a n come anytime." I s u g g e s t e d t o d a y b u t w a n t e d i t t o be a t a t i m e when  28 she was c o n v e n i e n t l y a t home. She t o l d me of some shopping to do t h i s morning b e f o r e B i l l y came home lunch. I wondered i f t h i s a f t e r n o o n would be agreeable 2 o'clock. She s a i d t h a t would be f i n e . I thanked her I'd be c a l l i n g on her l a t e r .  having for around and s a i d  Comment; There was some a n x i e t y i n Mrs. Anderson's tone and h e s i t a t i o n . T h i s l e s s e n e d when she was assured t h a t the c o n t a c t was d e f i n i t e l y to be geared to her convenience and t h a t she would not be pressed to d i s c u s s t h i n g s t h a t would embarrass her, e i t h e r from l a c k of knowledge o r , I assumed, i n r e l a t i o n t o p e r s o n a l i n v o l v e ment • Interview w i t h Mrs.  Anderson  At the b e g i n n i n g of the i n t e r v i e w Mrs. Anderson seemed anxious and found i t d i f f i c u l t to converse spontaneously. She r e l a x e d , somewhat, a f t e r I had d e s c r i b e d the purpose of my v i s i t . I hoped, from her p a s t experience w i t h the C l i n i c , t h a t she might c r i t i c i z e i t i n the l i g h t of her r e a c t i o n s and impressions. When I mentioned t h a t our i n t e r v i e w would be c o n f i d e n t i a l , she i n d i c a t e d t h a t i t d i d n ' t a f f e c t her one way or the o t h e r . Mrs. Anderson, a t f i r s t , s a i d the C l i n i c had helped h e r . I n t h i s connection she r e f e r r e d to her fondness of the s o c i a l worker. She then mentioned the w a i t i n g - p e r i o d ; "They t o l d me I'd hear from them i n December, but no one c a l l e d u n t i l J u l y . " By t h i s time, Mrs. Anderson continued, "the C l i n i c moved way out to Burnaby." She s t a t e d t h a t to take B i l l y out there would have meant h i s m i s s i n g a day of s c h o o l . To summarize her thoughts about the w a i t i n g - p e r i o d she s a i d : " i t was f a r too l o n g and made me l o s e i n t e r e s t . " I mentioned t h a t , had she r e t u r n e d to the C l i n i c a f t e r the w a i t i n g - p e r i o d , she would have had a d i f f e r e n t s o c i a l worker. She acknowledged t h i s , I asked i f t h i s was a reason f o r her d i s continuing C l i n i c contact. She had not g i v e n the matter much thought. She d i d suggest, however, " t h a t i t would be n i c e to have the same person r i g h t along" as she had thought so h i g h l y o f her worker. I s t i l l d i d n ' t have a c l e a r p i c t u r e about whether she had been s a t i s f i e d with the C l i n i c . She r e p l i e d , " w e l l , B i l l y stopped s t e a l i n g " . Did t h i s , I asked, occur about the time she was coming to the C l i n i c ? She c o u l d n ' t remember — but she'd t o l d him once and f o r a l l t h a t he could e i t h e r q u i t s t e a l i n g or get out. She would not t o l e r a t e a t h i e f i n the house. "I meant i t too — e i t h e r he q u i t or he got out". "So, he q u i t . " She then tended to d w e l l on B i l l y ' s p e r s o n a l i t y . "He has been miserable s i n c e the day he was b o r n — and s t i l l i s ; he bawled from morning t i l l n i g h t when a baby and he's s t i l l a c r y baby. He's a l s o s t i l l s t u t t e r i n g " ( f o r which she took him b r i e f l y to a speech t h e r a p i s t a f t e r b e i n g a t the C l i n i c ) . He a l s o had developed hay f e v e r which she t h i n k s i s t u r n i n g i n t o a c h r o n i c sinus c o n d i t i o n . " I d i d one t h i n g you (the C l i n i c ) t o l d me —  29 I gave i n and s t a r t e d doing up h i s shoe l a c e s f o r him and s t i l l do most of the time." She e l a b o r a t e d , s a y i n g t h a t she always had to f i g h t w i t h B i l l y t o t i e h i s shoes — h e r worker suggested t o her t h a t she might g i v e i n o c c a s i o n a l l y . I wondered i f a n y t h i n g e l s e came i n t o h e r mind b e s i d e the shoe l a c e s . She was d i s a p p o i n t e d i n the p s y c h i a t r i s t i n as much as she never d i d f i n d out what he thought o r what he'd s a i d to B i l l y . He "whisked B i l l y away and brought him back and t h a t was the l a s t I ever heard." She looked a t me i n t e n t l y , a s k i n g , "What does the p s y c h i a t r i s t say t o the k i d s ? " I thought perhaps his f i n d i n g s were i n c l u d e d i n what her worker had t o l d h e r a f t e r the d i a g n o s t i c c o n f e r e n c e . She couldn't remember. I n f a c t , she r e a l l y d i d n ' t f i n d out a n y t h i n g . I suggested she t h i n k of h e r own i n t e r v i e w w i t h t h e p s y c h i a t r i s t and she could then perhaps remember some of h i s t h i n k i n g . She couldn't r e c a l l seeing the p s y c h i a trist. Then, l o s t i n thought f o r a moment, she s a i d , "Oh yes — I d i d t a l k t o someone, but I t h i n k i t was a woman. Mrs. Anderson then asked me q u e s t i o n s about the C l i n i c a l o n g p r o c e d u r a l l i n e s . I questioned her about her understanding of p a r e n t a l i n volvement i n C l i n i c s e r v i c e s t o c h i l d r e n . She and her husband und e r s t o o d t h i s — then she s a i d , "I t o l d my worker t h a t I was proba b l y t o blame f o r B i l l y ' s t r o u b l e s , and I suppose I s t i l l am." I changed the s u b j e c t and wondered i f , on the whole, she f e l t she had not r e c e i v e d what f a c t u a l i n f o r m a t i o n she had hoped f o r i n order t o g e t a t B i l l y ' s problems. She s a i d t h a t was about i t . " B i l l y i s s t i l l a baby and won't l e t me out of h i s s i g h t — i n f a c t I have two b a b i e s , B i l l y and h i s Dad. Young S t e v l e , age 6 , doesn't l e t anything bother him and i s no t r o u b l e a t a l l . She d i d f e e l s o r r y f o r B i l l y and wished he was a h a p p i e r boy. I thought Mrs. Anderson had been most h e l p f u l and thanked her f o r t a l k i n g t o me. She was p l e a s e d t o do so — then asked i f we were s t i l l as busy as ever a t the C l i n i c ? I commented we had l o t s t o do t o keep us out of m i s c h i e f . She laughed, c a l l i n g t o me, "thanks f o r coming." I m p l i c a t i o n s o f I n t e r v i e w w i t h Mrs. Anderson. It the  would appear t h a t Mrs. Anderson's a t t i t u d e s toward  C l i n i c i n terms of h e r t o t a l C l i n i c experience a r e predom-  inantly negative. On the telephone Mrs. Anderson s t a t e d t h a t she would see me p r o v i d i n g she d i d n o t have t o come t o the C l i n i c . much "what" she s a i d as "how" she s a i d i t .  I t i s not so  I n e f f e c t , she would  r e s i s t any contact which i n v o l v e d h e r coming back. At  t h e b e g i n n i n g of the i n t e r v i e w h e r r a t h e r f l i p p a n t  30 a t t i t u d e toward my d i s c u s s i o n of c o n f i d e n t i a l i t y connoted a "don't care" a t t i t u d e which, i t would appear was d i l u t e ity.  Although she s a i d she was h e l p e d a t the C l i n i c ,  hostil-  she p r o -  ceeded i n a f a i r l y d i r e c t way t o show me e x a c t l y the r e v e r s e . Mrs. Anderson complained of the w a i t i n g p e r i o d , which we can reasonably assume was a conscious f a c t o r i n her d e c i s i o n t o withdraw.  She spoke e m p h a t i c a l l y and n e g a t i v e l y of the d l s *  tance t o Burnaby and remarked, that t o b r i n g B i l l y , would have d e p r i v e d him of a day i n s c h o o l .  She spoke p o s i t i v e l y o f her  s o c i a l worker although she hadn't thought much i n terms of r e a s signment: i . e . she presumably had d e c i d e d t o d i s c o n t i n u e r e g a r d l e s s of worker. With r e f e r e n c e t o B i l l y ' s problem she s t a t e d i t had changed i n as much as he was s t e a l i n g no l o n g e r . she went on to demonstrate c a r e f u l l y that i t was C l i n i c , who was  At that p o i n t she, and not the  Instrumental i n t h i s "improved" b e h a v i o u r .  Aside  from t h i s she d e s c r i b e d the boy as b e i n g "as m i s e r a b l e as ever" and s t i l l a " c r y baby."  H i s problems have i n c r e a s e d w i t h the on-  set of hay f e v e r and a s i n u s c o n d i t i o n .  The w r i t e r  interpreted  her remark about the shoe l a c e to be o f a snide n a t u r e ; a h o s t i l e rebuke• She showed a g e n e r a l l a c k o f understanding i n the a r e a of C l i n i c procedures and seemed to expect a l i s t which she might re-mould B i l l y .  of rules with  Such a m o d i f i c a t i o n , i t would  seem, would be more i n l i n e w i t h her own needs.  Her a b i l i t y t o  use the C l i n i c f i n d i n g s was reduced t o the q u e s t i o n of whether she should t i e B i l l y ' s shoe l a c e s or make him do t h i s f o r himself.  31  The w r i t e r f e l t our  she  d i d grasp some s i g n i f i c a n c e of  s t r e s s on p a r e n t a l p a r t i c i p a t i o n . T h i s , no doubt, produced  a n x i e t y which she  d i s t o r t e d into a h o s t i l e threat to h e r s e l f  which soothed the g u i l t aroused by her r e j e c t i o n of B i l l y . her  ego was  l e f t w e l l defended.  dependent on her Her  so t h a t she  She  Thus,  s a d i s t i c need to keep  can r e p u l s e him  v e r b a l i z e d wish t h a t B i l l y  attitude since C l i n i c  Her  be h a p p i e r  and  Billy  remains unchanged.  bespeaks an unchanged  contact.  expressed her  conscious  f e e l i n g s t h a t the  c o u l d improve i t s s e r v i c e s by p r o v i d i n g more f a c t u a l  Clinic  information  as a means of c o r r e c t i n g problems. Summary:  Mrs.  Anderson was  not h e l p e d by  c o n t i n u a t i o n would seem t o be  personal  to precede i n t e r n a l growth and  Case No.  dis-  waiting-  the l a c k of presupposed  h e l p but b a s i c a l l y r e f l e c t s the t h r e a t t o her ego  s u l t i n g r e s i s t a n c e to any  Her  c o n s c i o u s l y r e l a t e d to the  p e r i o d , d i s t a n c e to the C l i n i c , and ual  the C l i n i c .  and  fact-  the  re-  involvement which would have  changee  2 - L a r r y BENNETT  Mr. Bennett took the day o f f from work to contact the C l i n i c about h i s seven year o l d son, L a r r y . Both parents were seen the same day. They d e s c r i b e d L a r r y as h a v i n g a "tvfin-comp l e x " , b e i n g r e s e n t f u l and j e a l o u s of h i s t w i n b r o t h e r . He f e l t unwanted. They were a l s o concerned about such nervous h a b i t s as n a i l - b i t i n g and a "mean" a t t i t u d e i n p l a y . The twins' Sunday School t e a c h e r had recommended the C l i n i c txtfo years ago. The parents f e l t , at t h a t Jbime, t h a t they c o u l d continue without h e l p as they weren't d e s p e r a t e . Mr. & Mrs. Bennett b o t h impressed the worker as i n t e l l i g e n t but e s s e n t i a l l y c o l d p e o p l e . They appeared w i l l i n g to look i n t o t h e i r h a n d l i n g of L a r r y as they v e r b a l i z e d the b e l i e f t h a t the c h i l d ' s behaviour stems from the treatment he r e c e i v e s . "They were a b l e to i n t e l l e c t u a l i z e and use p s y c h o l o g i c a l t e r m i n ology but i t was d i f f i c u l t to know how s u p e r f i c i a l these were."  32 Mrs. Bennett had n i n e i n t e r v i e w s w i t h the worker. Throughout, she expressed an "understanding" of what L a r r y ' s behaviour a c t u a l l y meant. She c o u l d not, however, t o l e r a t e i t u n l e s s he c o u l d adapt i t t o her code of a c c e p t a b l e r u l e s of cond u c t . L a r r y would a c t out t o a t t r a c t her a t t e n t i o n when she was b u s i l y engaged i n some a c t i v i t y w i t h the b r o t h e r . To cope w i t h t h i s mother would push L a r r y away, r e j e c t i n g him completely u n t i l he c o u l d a p o l o g i z e . When t h i s f a i l e d she could " t r y something e l s e " . Her methods were i n c o n s i s t e n t , devoid of any warmth or attempts to t a l k through the d i f f i c u l t i e s w i t h L a r r y . She was f e a r f u l of h e l p i n g him through h i s behaviour d i f f i c u l t i e s l e s t she appear "condoning". Mr. Bennett, i n t e l l e c t u a l l y i n f e r i o r to h i s w i f e , a t tempted to convince the worker t h a t he knew a l l about c h i l d behaviour. He was unable t o c a r r y over h i s "knowledge" i n t o the realm of a p p l i c a t i o n . Rather, he adapted h i s p a r e n t a l r o l e t o the r i g i d mould expected by h i s w i f e . Both parents d e s c r i b e d L a r r y ' s t r a u m a t i c car a c c i d e n t when he was two and which i n v o l v e d months of treatment as w e l l as i n t e n s e s u f f e r i n g f o r the boy. They f e a r e d , however, t h a t he might use t h i s as a c r u t c h f o r the r e s t of h i s l i f e as a j u s t i f i c a t i o n f o r mis-behaviour. They spoke much more f o n d l y of the twin s i b l i n g — a more a p p e a l i n g boy, not so i n t e l l i g e n t as L a r r y , but a b e a u t i f u l l o o k i n g c h i l d who always r e c e i v e d f i r s t a t t e n t i o n from f r i e n d s and acq u a i n t a n c e s . Mrs. Bennett's c h i l d h o o d "couldn't have been h a p p i e r " . She seemed p a r t i c u l a r l y c l o s e t o her f a t h e r who was i n t e l l i g e n t , a h i g h s c h o o l headmaster, and "a very p r o g r e s s i v e t h i n k e r " "He was a s t r i c t d i s c i p l i n a r i a n but always f a i r " . Her mother "did not have f a t h e r ' s i n t e l l e c t but was more h i s p a s s i v e supporter". Mrs. Bennett had a s i s t e r and two b r o t h e r s . She a l s o had nursemaids u n t i l her e l e v e n t h y e a r . Her f a m i l y were f i r m b e l i e v ers i n "co-education". She s t u d i e d f o r a year a t an o u t s t a n d i n g U n i v e r s i t y and, d u r i n g the war, h e l d r e s p o n s i b l e p o s i t i o n s i n one of the armed'forces. She met Mr. Bennett overseas and came to Canada a f t e r the war t o marry him. She was very l o n e l y a t f i r s t and t h e r e are i n d i c a t i o n s of e a r l y m a r i t a l d i f f i c u l t y . ( S o c i a l S e r v i c e Index:recorded two contacts w i t h a f a m i l y agency. Mrs. Bennett would not g i v e the worker p e r m i s s i o n t o i n v e s t i g a t e these c o n t a c t s which she d e s c r i b e d as "help through an i n i t i a l p e r i o d of adjustment"). She s a i d the p e o p l e a t the f a m i l y agency were k i n d and t h a t she needed someone t o take the p l a c e of her mother over here. Since her marriage, Mrs. Bennett has cont i n u e d with her p r o f e s s i o n . She admitted the tremendous " d r a i n " of the. twins on both h e r s e l f and her husband. Although i t was a planned b i r t h , they .did not expect twins. Mr. Bennett from an e a r l y age, separated h i s home and school to pursue s p o r t s i n Canada and S t a t e s . He was one of e i g h t c h i l d r e n ; he t o l d the "unable t o r e c a l l much about h i s p a r e n t s " . During  h i m s e l f from the U n i t e d worker he was h i s three  33 i n t e r v i e w s he conveyed h i s f e e l i n g t h a t he wanted "advice" from the C l i n i c — "new ways o f h a n d l i n g s i t u a t i o n s . " He thought t h a t some "new methods might h e l p L a r r y to change h i s a t t i t u d e s . " The worker recorded: " i t i s my impression t h a t Mr. Bennett exp e c t s a g r e a t e r change i n L a r r y than he i s prepared t o make i n himself." Both parents were ambivalent about coming to the C l i n i c . Mrs. Bennett wondered how L a r r y would f e e l when he grew o l d e r and knew more about h i s contact a t the C l i n i c . She was adamant i n her r e f u s a l to t e l l him the purpose of the v i s i t s . Mrs. Bennett's d i s c u s s i o n s were i n t e l l e c t u a l and cont r o l l e d , with l i t t l e a f f e c t . She seemed i n h i b i t e d and f e a r f u l of showing any emotion. She was a l s o i n c l i n e d to t h i n k c a r e f u l l y b e f o r e speaking as i f she f e a r e d t h a t the meaning behind her words might be " s i g n i f i c a n t . " At d i a g n o s t i c conference L a r r y was seen as i n s e c u r e , dependent, and j e a l o u s . He saw h i s t w i n as being more favoured t h a n h i m s e l f . He showed many compulsive t r a i t s and was thought to be r e a c t i n g to the mechanistic h a n d l i n g of h i s mother i n her r e l e n t l e s s emphasis on p e r f e c t i o n and on good behaviour. Treatment would i n c l u d e a "de-emphasis" on Mrs. Bennett's p e r f e c t i o n i s t i c expectations. The team recommended t h a t the twins be p l a c e d I n separate rooms at s c h o o l . Continued s e r v i c e s were r e commended f o r L a r r y and the parents w h i l e the home s i t u a t i o n (concerning the other boy) was to be watched from, a p r e v e n t i v e standpoint. C l i n i c a l f i n d i n g s were i n t e r p r e t e d f i r s t t o Mrs. Benn e t t who "wrote e v e r y t h i n g down" as the worker t a l k e d . She was apprehensive of "treatment" and expressed c o n c e r n about her own r o l e i n i t . She agreed t o continue a f t e r the w a i t i n g p e r i o d and hoped her husband would i n c r e a s e h i s p a r t i c i p a t i o n . Mrs. Bennett r e f u s e d t o continue when c o n t a c t e d a f t e r a s i x month w a i t i n g p e r i o d . She s a i d she had l e a r n e d a l o t and t h a t they " c o u l d now cope q u i t e adequately w i t h the s i t u a t i o n " . Telephone  Contact  I telephoned Mrs. Bennett and e x p l a i n e d t h a t my purpose i n c a l l i n g was i n c o n n e c t i o n w i t h the D i r e c t o r ' s l e t t e r . She s a i d t h a n when she r e c e i v e d the l e t t e r she r e a l i z e d she would be away when I c a l l e d but t h a t t h e r e was no way to l e t me know. I a p p r e c i a t e d the s i t u a t i o n and wondered now i f i t would be poss i b l e f o r me t o see her as o u t l i n e d i n the l e t t e r . Quite q u i c k l y she s t r e s s e d her busy schedule — working f i v e days a week, w i t h only Saturdays and Sundays at home. Things are a d d i t i o n a l l y complicated at the moment because they are house h u n t i n g . I s a i d I c o u l d w e l l v i s u a l i z e how rushed she was. She asked me what I r e a l l y wanted to f i n d out i n the i n t e r v i e w , I mentioned the C l i n i c ' s I n t e r e s t i n g e a r i n g i t s e r v i c e s t o the needs of the  3^ community. We thought i t would be p a r t i c u l a r l y h e l p f u l t o t a l k to a few people who were, a t one time, i n c o n t a c t w i t h u s . I t was d i f f i c u l t s e l e c t i n g people but we had thought Mrs. Bennett c o u l d be very h e l p f u l . She t o l d me she had some knowledge o f t h e C l i n i c through p r o f e s s i o n a l c o n t a c t s . Then too, she c o u l d remember a l i t t l e of her own C l i n i c e x p e r i e n c e , a l t h o u g h i t was a long time ago and she " q u i t e a r l y " because she f e l t "there was no n e c e s s i t y to c a r r y on." I thought h e r comments would be e s p e c i a l l y h e l p f u l t o us, b o t h i n the l i g h t o f p e r s o n a l and p r o f e s s i o n a l experi e n c e . She wondered i f she might suggest a t e n t a t i v e date now f o r some Saturday and c a l l me t o change I t i f n e c e s s a r y . I thought t h a t would be f i n e and wondered i f she would r a t h e r t h i n k about a time over t h i s weekend and c a l l me next week. Mrs. Benn e t t was p l e a s e d w i t h these arrangements. She presumed "an hour" would take care o f t h e i n t e r v i e w t o which I agreed r e a d i l y . I thanked h e r and would be e x p e c t i n g h e r c a l l . Comment: Mrs. Bennett had a r e f i n e d , European a c c e n t . She was apprehensive and r e s i s t i v e a t the b e g i n n i n g , but mellowed when I was a b l e t o appeal t o h e r v a n i t y , i . e . "she" c o u l d be especi a l l y helpfulo I n t e r v i e w w i t h Mr. & Mrs. Bennett. Mr. and Mrs. Bennett welcomed me w i t h a s l i g h t r e s e r v a t i o n . I c o u l d hear t h e c h a t t e r of boys' v o i c e s behind a c l o s e d door. While Mrs. Bennett went i n t o " s e t t l e them down" I c h a t t e d t o h e r husband. He was c l a d i n a d r e s s i n g gown and hoped I d i d n ' t mind. He'd had a busy day and f e l t l i k e r e l a x i n g t o n i g h t . Mrs. Bennett j o i n e d us i n the l i v i n g room and I exp l a i n e d t h e purpose of my v i s i t . The C l i n i c , always anxious t o adapt i t s s e r v i c e s t o the changing community, was i n t e r e s t e d i n the suggestions and f e e l i n g s o f people who had come f o r h e l p i n the p a s t . Mr. Bennett asked i f I were i n t e r v i e w i n g a c r o s s s e c t i o n o f our former c l i e n t e l e . I t o l d him t h a t was p r e t t y much i t — I hoped t o g e t a broad range o f i d e a s and c r i t i c i s m s . Looking d i r e c t l y a t me, Mrs. Bennett s a i d , " I presume you wish us t o be p e r f e c t l y f r a n k . " I a s s u r e d h e r of t h i s . She t h e n t o l d me the C l i n i c hadn't a t a l l g i v e n them the k i n d o f h e l p they wanted — "or needed, f o r t h a t matter". Of course, "we j u s t came t o the C l i n i c to see what i t had t o o f f e r . " Mrs. Benn e t t continued, e x p l a i n i n g h e r c o n t e n t i o n that the C l i n i c never d i d get t o the "core" o f t h e problem. "They c o n c e n t r a t e d on us i n s t e a d of on L a r r y . " Mr. B n n e t t spoke up s a y i n g t h a t t h e i r problem w i t h L a r r y was not " c u t and d r i e d " l i k e he supposed many f a m i l y p r o blems were. I f a c h i l d were m e n t a l l y r e t a r d e d , o r had a "hate" complex, or some other gross p e r s o n a l i t y d i s t u r b a n c e , he thought e  35 the C l i n i c might he a b l e t o do something about i t . Mrs. Bennett added, too, t h a t " i f the problem was w i t h the p a r e n t s , r a t h e r than the c h i l d " i t might be s u i t e d t o the C l i n i c ' s way of " t r e a t ing". Both f e l t t h e i r problem d i d not f i t i n t o any of these categories. Mrs. Bennett continued: "and I c e r t a i n l y d i d n ' t approve o f the way they planned to t r e a t L a r r y ; I j u s t don't bel i e v e i n i t " . I asked i f she would e l a b o r a t e . "Well, the worker t o l d me someone would see L a r r y f o r an hour a week or every two weeks ("or whatever i t was"); d u r i n g t h i s hour he'd be g i v e n complete freedom of e x p r e s s i o n . I f he f e l t l i k e w r i t i n g on the w a l l s or b e i n g d e s t r u c t i v e , ( " n o t t h a t I t h i n k he ever would, mind you"), the behaviour would be p e r f e c t l y a c c e p t a b l e . "Just t h i n k what I'd have had to put up w i t h - you people l e t t i n g him do e x a c t l y as he chose, then he'd expect t o do the same t h i n g a t home - I don't b e l i e v e i n i t a t a l l " . I accepted t h i s and wondered i f t h i s was the i n t e r p r e t a t i o n of "treatment" as g i v e n to her by the worker. She thought so. She remembered the worker's emphasis on a " r e l a x e d , permiss i v e atmosphere". I s a i d t h i s might p o s s i b l y i n c l u d e a r e - d i r e c t ' ing or unacceptable behaviour. She replied., "now, I do b e l i e v e i n t h a t " . Here, Mr. Bennett t o l d me how he attempts t o d i s t r a c t L a r r y ' s a t t e n t i o n when he i s a c t i n g out i n a d e s t r u c t i v e way. He thought t h i s was a good " r u l e to f o l l o w " but i t was j u s t as e a s i l y done a t home as a t the C l i n i c . Mrs. Bennett, w a i t i n g i m p a t i e n t l y f o r her husband to f i n i s h , s a i d , "mind you, we knew what was a t the core of L a r r y ' s problem. He was t e r r i b l y i n j u r e d when he was two. Mr. Bennett i n t e r r u p t e d and t o l d me of the t r a u m a t i c o r d e a l which L a r r y had s u f f e r e d - e x c r u c i a t i n g p a i n , weeks o f • h o s p i t a l i z a t i o n , s k i n g r a f t i n g , and months of d r e s s i n g s and anguish. "He emerged a complete nervous wreck". His w i f e supported him, s a y i n g t h a t the d o c t o r ("who was a l o v e l y woman") warned them i t would take years f o r L a r r y t o outgrow the severe damage he had s u f f e r e d . "Of course t h e r e were other s m a l l e r t h i n g s " . L a r r y ' s twin b r o t h e r was a " b e a u t i f u l baby", endowed w i t h charm and a p p e a l . Prom the very b e g i n n i n g people took to him f i r s t . Even b a b i e s , she f e l t , can sense how others f e e l toward them. "Larry has always had a twin-complex and had f e l t i n the background where h i s b r o t h e r i s concerned". I n o t i c e d Mrs. Bennett spoke warmly and proudly of the other boy, and more m e c h a n i c a l l y of L a r r y . "At the time we came to the C l i n i c I was d e s p e r a t e not knowing now to handle L a r r y " , I asked whether or not the problem had changed s i n c e t h e i r C l i n i c c o n t a c t . She s a i d he i s improving s l o w l y , and looked t o her husband f o r c o n f i r m a t i o n . She quoted a f r i e n d who made the f o l l o w i n g o b s e r v a t i o n of the boys when they were f i v e years o l d , "Larry w i l l get t o the top, r e g a r d l e s s how he does i t or on whose toes he may t r e a d : the other boy w i l l get t o the top too, but i t w i l l be because of h i s simple, p l e a s a n t , s i n c e r e and a p p e a l i n g p e r s o n a l i t y " , Mrs.  36 Bennett s a i d she c o u l d n ' t bear to t h i n k o f L a r r y going through l i f e without s c r u p l e s . I s a i d they might have some a d d i t i o n a l thoughts about the C l i n i c t o g i v e me. I wondered i f they'd f e l t any r e a c t i o n to the w a i t i n g p e r i o d . Mrs. Bennett r e p l i e d i n s t a n t l y : " I meant t o b r i n g that up - " I t ' s a t e r r i b l e t h i n g - why, when I was phoned a f t e r a l l those months i t was l i k e a b o l t out o f nowhere." She thought most people had t o "get up a l o t o f nerve to ask t h e C l i n i c f o r h e l p i n the f i r s t p l a c e — t o her, the w a i t i n g p e r i o d j u s t added i n s u l t t o i n j u r y . " Mr. Bennett confirmed t h i s s a y i n g the wait caused t h e i r f i n a l d e c i s i o n not t o c o n t i n u e . He s a i d , " i f you'd get r i d of t h a t , you probably wouldn't l o s e so many people." Mrs. Bennett s a i d she enjoyed h e r two v i s i t s w i t h t h e p s y c h i a t r i s t , "not that she h e l p e d me but our t a l k s were I n t e r esting." She r a t h e r l i k e d t a l k i n g t o the caseworker t o o . "But, I went f o r i n t e r v i e w a f t e r i n t e r v i e w , time a f t e r time, and we t a l k e d and t a l k e d — mostly about me and what L a r r y had done the week b e f o r e . A l l mothers, I presume, enjoy t a l k i n g about t h e i r c h i l d r e n , but t h i s wasn't s o l v i n g our problem." She knew i t was a b s o l u t e l y i m p o s s i b l e f o r anyone t o g i v e a t r u e p i c t u r e o f how one member o f a f a m i l y behaves. I s a i d she f e l t an i n d i v i d u a l c o u l d not be i s o l a t e d from the f a m i l y as a whole. "That's i t exactly." Mr. Bennett expressed h i s f e e l i n g , saying" he spoke f o r h i s w i f e as w e l l , that the C l i n i c wasted hours g o i n g i n t o t h e i r backgrounds. " I f we had been p a r t of the problem, t h e n O.K. "As I t was, they c o u l d have l e a r n e d a l l that was necessary about our c h i l d h o o d s i n h a l f an hour." H i s wife s a i d she understood the C l i n i c ' s concern w i t h f i n d i n g out whether "our c h i l d h o o d s were happy and our parents maladjusted"; but, she f e l t , t h e worker should have sensed t h a t she was "overdoing i t " and not g e t t i n g anywhere. When I asked about improvements i n our s e r v i c e s , they v i s u a l i z e d as d e s i r a b l e , Mrs. Bennett s a i d , "Well, i f you a r e going t o pursue t h i s l o n g term treatment you need a home where the c h i l d r e n can " l i v e i n " and are exposed t o your k i n d of t r e a t ment-atmosphere twenty-four hours a day. She r e p e a t e d that an hour a week was, i n h e r o p i n i o n , l i t t l e b e t t e r t h a n n o t h i n g . I t a l k e d a l i t t l e about the need f o r a home f o r e m o t i o n a l l y d i s t u r b e d c h i l d r e n i n the Vancouver a r e a and s t r e s s e d the need f o r community support. I a l s o wondered i f Mrs. Bennett thought t h a t a l l c h i l d r e n who came to the C l i n i c needed t h i s type o f home. She thought so, i f our treatment was t o be e f f e c t i v e —  37 otherwise, the parents would undo "any good" the c h i l d d e r i v e from the weekly appointments.  might  She thought a moment, then s a i d , "and another ghing — the worker made a home v i s i t which I thought was a l r i g h t but a complete waste of my time and h e r s . " The worker wanted to "see where L a r r y l i v e d , h i s room, and I suppose, how he f i t i n t o the f a m i l y . W e l l , "you can't l e a r n a l l that i n one v i s i t — the c h i l d r e n were n a t u r a l l y on t h e i r b e s t behaviour. I n some cases I t h i n k such a v i s i t would be d e s i r a b l e , but i n ours, t h e r e was no p o i n t t o i t , (not t h a t I minded, o f c o u r s e ) . " I s a i d s o c i a l workers q u i t e o f t e n v i s i t e d homes and a l s o s c h o o l s i f the c l a s s room was a p a r t of the problem. T h i s prompted Mrs. Bennett t o t a l k about the problems which she had heard d i s c u s s e d a t P.T.A. She asked what the C l i n i c does w i t h c h i l d r e n r e f e r r e d by the s c h o o l s ? She then d e s c r i b e d t h e i r p r i n c i p a l , a f a m i l y man of wide v i s i o n who arranged panel d i s c u s s i o n s r e g u l a r l y on c h i l d behaviour to h e l p the parents i n the d i s t r i c t . Mr. Bennett s a i d t h i s was a good i d e a as parents came to f e e l they were not alone w i t h t h e i r problem c h i l d r e n . Mrs. Bennett f e l t she got more h e l p from the panels than she had any o t h e r p l a c e . We c h a t t e d p l e a s a n t l y f o r a few moments. When l e a v i n g , both Mr. & Mrs. Bennett f o l l o w e d me to the door and thanked me f o r coming. Mrs. Bennett s a i d shehad " q u i t e enjoyed our t a l k and she hoped our paths would c r o s s a g a i n sometime." I m p l i c a t i o n s of I n t e r v i e w w i t h Mr. and Mrs. Bennett Both parents demonstrated g r e a t h o s t i l i t y toward a complete r e j e c t i o n of t h e i r C l i n i c e x p e r i e n c e .  and  T h i s , the w r i t e r  suggests, r e f l e c t s t h e i r b a s i c p e r s o n a l i t y p a t t e r n s , o r a t l e a s t , the  i n t e r a c t i o n of these p a t t e r n s .  Mrs. Bennett's g r e a t need  s i n c e youth has been to be i n t e l l e c t u a l l y s u p e r i o r to a l l males. While the case h i s t o r y p o i n t s out her attachment the  writer f e l t  hostility.  there was  She was  t o her f a t h e r ,  a l s o an undertone o f c o m p e t i t i o n and  compelled to be h i s i n t e l l e c t u a l equal and  f e l t d i s d a i n f u l of her mother.who was h i s " p a s s i v e s u p p o r t e r " . She i s b a s i c a l l y n a r c i s s i s t i c , t o l e r a t i n g n o t h i n g which t h r e a t e n s her own  s t r i v i n g s toward p e r f e c t i o n .  She m a r r i e d a man who  is  i n t e l l e c t u a l l y i n f e r i o r t o h e r s e l f and whom she can m a n i p u l a t e . L a r r y , who  i s s t r o n g - w i l l e d and i n t e l l i g e n t , t h r e a t e n s her pos-  i t i o n as a s u p e r i o r female and r e a c t i v a t e s b a s i c c h i l d h o o d  38 conflicts  of dominant male f i g u r e s .  c h i l d who  does n o t  threaten  because of h i s f i n e looks  or q u e s t i o n  and  i s a near perfect production strengthen  her  She  her  appealing, of her  can a c c e p t the  own  s t a t e d t h a t they were not  The  writer felt  w a i t was,  need t o n o u r i s h  not  not  i s b a s e d on t h e  still  operating  Involve  s c h e d u l e , Mr.  s a t i s f i e d with the  Clinic's  f a c t that the  themselves i n the  r a t h e r t h a n t o any  help  services.  end,  and  relationship with their  s e e m i n g l y be  t o t h e i r own  t o l e r a t e any  no  o u t s i d e h e l p was  versatile disciplinary  to d e a l with the problem.  suggestion  The  that only  that her  approach the  Interviews,  "Core" of the  by  themselves  i s s u b s t a n t i a t e d by  focusing  part that  "they" were equipped  B e n n e t t ' s f e e l i n g t h a t t h e w o r k e r ' s home v i s i t was and  did  Bennetts'  conscious a p p r e c i a t i o n of the  parental p a r t i c i p a t i o n . This  methods  Clinic  They s t r o n g l y r e s i s t e d p e r s o n a l  a p p e a r e d t o h a v e no  did  o f t h e i r own  so w i s h e d t o r e a s s u r e  a v a i l a b l e and  was  improving.  They c o u l d n o t  c r e a t i n g t h e p r o b l e m and  assumpt-  too d i s t u r b i n g t o them.  r e c e i v e d from the C l i n i c .  in  the  worker.  wanted.  time,  them.  that both parents  - w h i c h , i t w o u l d a p p e a r , i s p r e c i s e l y what t h e  for  "losing  This  not help  ment a n d  Bennett  i n i t i a l resistance to help  problem, they s t a t e d i s g r a d u a l l y  i m p r o v e m e n t i s due  Mrs.  i n terms of our  a f a c t o r i n t h e i r withdrawal.  s t r o n g l y at the  Larry's  and  change i n s o c i a l w o r k e r s f o l l o w i n g  Hence, a change would n o t  The  he  and  f o r some r e a s o n , i n t o l e r a b l e t o  that the  w a i t i n g p e r i o d was ion  Also,  pliable personality,  They s t r o n g l y condemned t h e w a i t i n g p e r i o d The  superiority.  narcissism.  I n d i r e c t response t o the  clients".  other  Involveneed  Mrs.  a waste  of  on h e r s e l f , n e v e r d i d  problem.  Their suggestions f o r C l i n i c  improvements were g e a r e d  39 toward a g r e a t e r  awareness needed  to help people.  M r s . Bennett  "Clinic  home,  also  c h i l d r e n " w h i c h seemed t o  She m i g h t h a v e b e e n  saying,  I would r a t h e r n o t Both parents  their hostility opportunity  to  by t h e  "if I  exemplify can't  their  feelings.  Because  that  case.  Mrs. Bennett  the  it  to  a parent  assume t h i s  from  was  Larry.  at having of  their  Mrs. Bennett,  entirely  of  at  the  strong  they  fault  and  the  discontinuation.  w o u l d seem,  the  conforming c h i l d .  as  of  a cultural factor  in  this  was r e a r e d i n a p a r t i c u l a r s t r a t u m E u r o p e a n  f o r h e l p would immediately competency  Clinic  in their  s o c i e t y which emphasizes obedient,  the  acceptance  They were p l e a s e d  consciously  also,  her r e j e c t i o n  the w r i t e r ' s  p a r t i c u l a r l y those of  There i s  "home" f o r  do a n y t h i n g w i t h h i m a t  d e f e n c e mechanisms,  only determing f a c t o r  "how"  have him a r o u n d . "  and c r i t i c i s m s .  believe  i n deciding  suggested a  responded to  ventilate  staff  so  dominant, Larry's  create  intelligent  the  p r o b l e m s a n d h e r own a p p e a l  a conflict.  obviously  p a r e n t and  With her s t a t u s  threatened,  as b e i n g a c o n t r i b u t i n g f a c t o r  it  is  not  and  difficult  to her withdrawal  treatment.  Case No.  3 -  Jimmy COOK  D r . M . r e f e r r e d Jimmy, age e i g h t y e a r s , a n d a c c o m p a n i e d M r s . Cook t o t h e C l i n i c t o g i v e s t a t i s t i c a l i n f o r m a t i o n . Mrs. Cook d e s c r i b e d Jimmy a s a n i n o r d i n a t e l y a g g r e s s i v e c h i l d who was without playmates f o r t h i s r e a s o n . A t home Jimmy was p a r t i c u l a r l y j e a l o u s o f h i s o l d e r b r o t h e r a n d when t e a s e d , w o u l d " f l y i n t o a f r e n z y " a n d become d e s t r u c t i v e . A l t h o u g h a s t o i c where p a i n was c o n c e r n e d , he c o n t i n u a l l y w h i n e d a n d c r i e d when f r u s t r a t e d by h i s parents or s i b l i n g s . "He o c c a s i o n a l l y h a s p e r i o d s when he wets t h e b e d e v e r y n i g h t , a n d a l s o messes h i s p a n t s " . H i s m o t h e r a l s o comp l a i n e d t h a t he a t e r e b e l l i o u s l y . "Mrs. Cook", r e c o r d e d the w o r k e r , "made i t c l e a r t h a t she i s v e r y much d i s g u s t e d by messy e a t i n g and t o i l e t h a b i t s " . The symptoms o f J i m m y ' s d i s t u r b a n c e were e v i d e n t l y i n a r e a s w h i c h h a d s p e c i a l m e a n i n g f o r h i s m o t h e r . D u r i n g t h e f i r s t i n t e r v i e w she was, a t one p o i n t , on t h e v e r g e o f  40 r e c o g n i z i n g her r e j e c t i o n of Jimmy - " l i f e would be so easy i f i t weren't f o r him". She asked the worker f o r "guidance i n h a n d l i n g Jimmy". Mr. Cook was n o t c o o p e r a t i v e w i t h the C l i n i c and d i d not come f o r an i n t e r v i e w b e f o r e the s o c i a l h i s t o r y was w r i t t e n . The worker deduced from Mrs. Cook's remarks t h a t h e r husband had a more " s t r a i g h t forward r e l a t i o n s h i p w i t h the c h i l d r e n than she", w i t h l e s s ambivalence. H i s a t t i t u d e toward Jimmy's problem was e n t i r e l y detached and u n i n v o l v e d as i n d i c a t e d i n h i s i n t e r v i e w w i t h the psyc h i a s t r i s t . He s a i d he was away from home a l o t , but " t r i e d " t o p l a y w i t h Jimmy when i t was p o s s i b l e . He expressed r i g i d i t y about a l l t h e c h i l d r e n " e a t i n g e v e r y t h i n g t h a t was on the t a b l e " . He was more i n c l i n e d t o d i r e c t t h e p s y c h i a t r i s t ' s a t t e n t i o n toward h i m s e l f , f o r he s a i d "Jimmy understands me b e t t e r than my w i f e " . I t was recorded, "Mr. Cook- i s somewhat opposed t o the C l i n i c , f e e l i n g t h a t h i s w i f e i s exaggerating h e r t r o u b l e s w i t h Jimmy". Mrs. Cook was r a i s e d i n a "very l o v e a b l e " f a m i l y i n which she was t h e o l d e s t c h i l d . She had one b r o t h e r e i g h t years h e r j u n i o r . She s a i d l i t t l e o f h e r f a t h e r but d e s c r i b e d her s t r o n g t i e t o h e r mother f o r whom she q u i t s c h o o l and whom she nursed when she s u f f e r e d a nervous breakdown a t menopause. There were i n d i c a t i o n s of s t r o n g s i b l i n g r i v a l r y f o r her mother's a t t e n t i o n . "My b r o t h e r was a strange c h i l d who s t i l l l i v e s w i t h my widowed mother and f i n d s i t h a r d t o make f r i e n d s . " "My d o c t o r t o l d me one time t h a t I was t o o c l o s e t o my mother - but I t e l l h e r a l l my t r o u b l e s - you have t o t e l l them t o someone". Her f a t h e r , now dead, seemed t o p l a y a minor r o l e i n the f a m i l y c o n s t e l l a t i o n . Mr. Cook had a d e p r i v e d c h i l d h o o d , b e i n g r a i s e d by housekeepers and nurses because o f h i s mother's c h r o n i c i l l h e a l t h from the time o f h i s b i r t h u n t i l h e r death e i g h t e e n years l a t e r . H i s f a t h e r was away most o f t h e time o p e r a t i n g a f l e e t o f t r u c k s . At the present time he has a good job and p r o v i d e s w e l l f o r h i s f a m i l y . He i s gregarious.and "loves t o e n t e r t a i n " . T h i s i t seems, is for self-glory. The b i g g e s t problem and the one which seemed t o concern Mrs. Cook p r i m a r i l y was h e r m a r i t a l t r o u b l e s . Her husband "ran around" a f t e r t h e i r marriage and "drank h e a v i l y " . "The only time he has ever showed any concern f o r me i s when I am s i c k and unable to do the work". She was very i l l d u r i n g h e r f i v e pregnancies (the t h i r d c h i l d d i e d a t the age o f e i g h t weeks). A f t e r t h e f o u r t h was conceived, Mr. Cook t h r e a t e n e d t o l e a v e h i s w i f e u n l e s s she got r i d o f i t . "However, he s a i d the same t h i n g next time b u t he grew t o l i k e t h e two youngest c h i l d r e n - e s p e c i a l l y the baby g i r l " . Jimmy, the second c h i l d , was c o n c e i v e d "to draw us c l o s e r t o g e t h e r " . The marriage has been a s e r i e s o f d i s p u t e s , a l l e g a t i o n s , s e p a r a t ions w i t h Mrs. Cook going home t o mother, and r e c o n c i l i a t i o n s . She r e s e n t s h e r husband l e a v i n g t o h e r the major r e s p o n s i b i l i t i e s f o r the c h i l d r e n , y e t r e b e l s when he makes s u g g e s t i o n s . As a r e s u l t , he undermines h e r a u t h o r i t y w i t h the c h i l d r e n . The worker d e s c r i b e d Mrs. Cook as "an extremely immature person who f i n d s i t d i f f i c u l t t o meet the demands p l a c e d upon her as a w i f e and mother and who p r o j e c t s the blame f o r t h i s upon her /  41 husband who f a i l s t o meet h e r immature dependency needs". She i s a f f e c t i o n a t e and p a t i e n t w i t h s m a l l babies but cannot t o l e r a t e the f r u s t r a t i o n s imposed by growing c h i l d r e n w i t h t h e i r m u l t i p l e demands. During t h e " i n t a k e study, she t a l k e d u n h e s i t a t i n g l y . Her a f f e c t was expressed through grimaces and expressions o f d e j e c t i o n . She was apprehensive about b r i n g i n g Jimmy l e s t the s c h o o l o r neighbors f i n d o u t . Jimmy was very f e a r f u l when seen a t t h e C l i n i c , r e f u s i n g to l e t the p s y c h i a t r i s t approach him. C l i n i c f i n d i n g s showed him to f e a r r e j e c t i o n , have few i n n e r s t r e n g t h s , and d e s i r i n g t o i d e n t i f y w i t h f a t h e r and be dependent upon mother but e x p e r i e n c i n g extreme f r u s t r a t i o n i n b o t h . " I n t e n s i v e treatment of Jimmy and both p a r e n t s " was recommended a t the d i a g n o s t i c conference. Mrs. Cook came f o r the r e p o r t s a t which time the worker emphasized the need f o r c o n s i s t ency and p a r e n t a l c o o p e r a t i o n i n h a n d l i n g the c h i l d r e n . Jimmy's need f o r approval and dependency was a l s o s t r e s s e d . Mrs. Cook showed l i t t l e o r no a p p r e c i a t i o n of the f i n d i n g s but tended t o d i s c u s s h e r own poor h e a l t h . She planned t o have an o p e r a t i o n which would h o p e f u l l y improve her h e a l t h and h e l p her t o meet h e r husband's ^standards o f housekeeping and t o be more i n t e r e s t e d i n Jimmy". She accepted the w a i t i n g p e r i o d and s a i d t h a t by autumn she would be a b l e t o p l a y a more e f f e c t i v e p a r t i n h e l p i n g Jimmy. A f t e r a waiting p e r i o d of nine to continue treatment, s a y i n g t h a t Jimmy although he s t i l l "has tempers and c r i e s her d e n t i s t d i s c o v e r e d an abscess on one thought t h i s might have been c a u s i n g the Telephone  months Mrs. Cook d e c l i n e d had improved I n many ways without reason". Also, o f Jimmy's t e e t h and he behavioural disturbances.  Contact  When I c a l l e d Mrs. Cook she, u n f o r t u n a t e l y , had n o t r e c e i v e d the l e t t e r and was thus caught q u i t e ' o f f guard'. I exp l a i n e d the purpose f o r the c o n t a c t r e l a t i n g I t t o the study I had undertaken. She s a i d , "do you want t o t a l k t o me about Jimmy?" I r e i t e r a t e d t h a t the purpose u n d e r l y i n g the suggested i n t e r v i e w was t o f i n d out what she thought about the C l i n i c based on her exp e r i e n c e w i t h i t some time ago. We were concerned about what we might do t o be more h e l p f u l . Mrs. Cook d e s c r i b e d the C l i n i c with some degree o f p l e a s u r e , but added: "I guess i t d i d me more good than Jimmy". She s a i d she had been helped t o understand Jimmy although he i s s t i l l s u b j e c t t o " f i t s of bad behaviour". Later, she s t a t e d , "they made me wait f o r a y e a r " . I s a i d these were the t h i n g s that would be h e l p f u l t o u s . She t o l d me of b e i n g I n poor h e a l t h - she never knew ahead of time when she might be c o n f i n e d t o bed f o r the day. Then, she asked a b r u p t l y , "when do you want t o come?" I t o l d her t h a t Tuesdays and Thursdays were my.*- days f o r these v i s i t s . She wondered i f I c o u l d c a l l back a week from today. She might be f e e l i n g b e t t e r by t h e n and she would t h i n k about i t i n the meantime. Comment: Mrs. Cook spoke smoothly and f l u e n t l y and was w e l l i n c o n t r o l . She r e s i s t e d my s u g g e s t i o n o f an i n t e r v i e w . I t  42 was thought that the a r r i v a l of the l e t t e r might h e l p t o a l l e v i a t e any a n x i e t y which the telephone c a l l produced. One Week L a t e r I c a l l e d the Cook home a g a i n . Mr. Cook answered and t o l d me h i s w i f e was not w e l l and was spending the day i n bed. He had a p l e a s a n t , f r i e n d l y manner. He wondered who was c a l l i n g and seemed i n t e r e s t e d . He suggested I c a l l back i n a few days as he thought Mrs. Cook would be b e t t e r by then. Three Days L a t e r I spoke t o Mrs. Cook today. She s a i d her h e a l t h had not improved and t h a t she p r e f e r r e d not t o have v i s i t o r s . I understood and s a i d I should perhaps not p l a n to have the i n t e r v i e w . This r e l i e v e d her; she f e l t i t was such a l o n g way f o r me to come and t o l d me how d i f f i c u l t i t was t o l o c a t e t h e i r home. A l s o , "I'm sure I wouldn't be a b l e t o h e l p you - I t o l d you e v e r y t h i n g l a s t time on the phone". I remembered she had mentioned the C l i n i c . She s a i d as f a r as she was concerned Jimmy wasn't h e l p e d a t a l l . " A l l they d i d was g i v e him a few t e s t s l i k e p u t t i n g beads on a string. Ohere's never been a n y t h i n g wrong w i t h h i s i n t e l l i g e n c e he does a l r i g h t i n s c h o o l " . I appeared i n t e r e s t e d so she c o n t i n u e d : "They t o l d me t h e r e was a problem behind h i s behaviour - but i n s t e a d of doing something, they l e t us wait n e a r l y a y e a r " . I s a i d the w a i t i n g p e r i o d seemed t o be a major f a c t o r i n her d e c i s i o n not t o r e t u r n t o the C l i n i c . She s a i d i t c e r t a i n l y was. "The C l i n i c d i d n ' t have e i t h e r the s t a f f nor the f a c i l i t i e s t o handle our problem". I asked i f Jimmy's problem had changed s i n c e the time he was seen a t the C l i n i c . Mrs. Cook r e p l i e d : "he i s changing very slowly - but he's s t i l l m i s e r a b l e a l o t of the time, c r i e s , and t h i n k s nobody l o v e s him". Here, Mrs. Cook s i g h e d as i f the whole t h i n g were j u s t too much f o r h e r . I wondered i f she had any thoughts about her own exp e r i e n c e a t the C l i n i c . She thought a moment, then s a i d , "They should have spent l e s s time, g o i n g i n t o my background and c o n c e n t r a t ed more on Jimmy - e s p e c i a l l y when we were going t o have t o wait so l o n g " . She concluded by s a y i n g Jimmy was s t i l l a r e a l problem, and w i t h her f e e l i n g s i c k most of the time and having t o l o o k a f t e r a l a r g e f a m i l y , i t was very d i f f i c u l t f o r h e r . I c o u l d understand t h a t i t was hard and hoped she would be f e e l i n g w e l l a g a i n soon. D i s c u s s i o n and I m p l i c a t i o n s of the Cook Case Although the w r i t e r was p e r s o n a l l y , i t was  unable t o i n t e r v i e w Mrs. Cook  f e l t t h a t s u f f i c i e n t m a t e r i a l was  gained by  telephone t o warrant u s i n g the case i n t h i s s e c t i o n of the study. Mrs. Cook c l e a r l y demonstrated at  the C l i n i c .  that she was not h e l p e d  She complained b i t t e r l y about the w a i t i n g p e r i o d  4  3  and seemed t o i n t e r p r e t i t as r e j e c t i o n — year". was  "They made us wait a  There were no i n d i c a t i o n s whatever i n the r e c o r d t h a t she  p e r s o n a l l y i n v o l v e d i n Jimmy's problems except i n so f a r as  they were of constant annoyance t o h e r . ness o f h e r r o l e i n the C l i n i c procedures participation; background".  She a l s o g a i n e d no awareor o f t h e need f o r parent  "they should have spent l e s s time going i n t o my She was not helped by h e r husband who, a c c o r d i n g t o  h i s p a t t e r n , allowed h e r t o assume the r e s p o n s i b i l i t y o f coming t o the C l i n i c .  Jimmy's problem has, a p p a r e n t l y , changed very  which might be expected  little  I h view of h i s mother's p e r s i s t i n g  attitudes. The main problem i n t h i s case a t the time of C l i n i c contact would seem t o have been the m a r i t a l a r e a .  While  Mrs. Cook  openly denounced Jimmy's behaviour,  i t was on h e r r e l a t i o n s w i t h  Mr. Cook t h a t she tended t o d w e l l .  Jimmy seemed caught  c o n f l i c t and was r e a c t i n g almost a p p r o p r i a t e l y .  i n the  The s i t u a t i o n , o f  course, was aggravated because o f h i s dependent t i e t o h i s mother. I t i s i n t e r e s t i n g t o r e c a l l Mrs. Cook t e l l i n g h e r worker that t h e only time h e r husband took any n o t i c e o f h e r was when she was  ill.  When t h e w r i t e r c a l l e d r e c e n t l y on t h r e e d i f f e r e n t  i o n s , she was i n bed and, work. was  occas-  on one of these, Mr. Cook was home from  T h i s was i n the middle of the day. She i n t i m a t e d t h a t she  chronically i l l  which would seem t o p o i n t out a p e r s i s t e n c e and  i n t e n s i f i c a t i o n o f t h e p a t t e r n she demonstrated a t the C l i n i c two years ago. D i s c o n t i n u a t i o n would seem t o r e f l e c t the w a i t i n g p e r i o d and a f e e l i n g of n o t b e i n g helped, on the conscious l e v e l , but a l s o a l a c k o f m o t i v a t i o n and r e s i s t a n c e t o change and p e r s o n a l involvement  on t h e unconscious.  44 Case No. 4  -  Judy DAVIS  Mrs. Davis c a l l e d the C l i n i c t o r e f e r her n i n e year o l d daughter, Judy. The c a l l was made a f t e r she and her husband had d i s c u s s e d the problem w i t h a s o c i a l worker f r i e n d . Mrs. Davis expressed concern about Judy's nervousness and d i s c o n t e n t and about s e v e r a l i n c i d e n t s of s t e a l i n g . She a l s o d e s c r i b e d the motherdaughter r e l a t i o n s h i p as tense and uncomfortable. Judy was showi n g i n t e n s e s i b l i n g r i v a l r y w i t h her t h r e e y e a r o l d s i s t e r . Both g i r l s were born w i t h c o n g e n i t a l eye d e f e c t s which r e q u i r e d surgery. Mrs. Davis s a i d , "Judy does not c o n f i d e i n me" "gets along much b e t t e r w i t h my husband than w i t h me".  and  she  I t was not p o s s i b l e f o r the w r i t e r t o a s c e r t a i n the exact number of i n t e r v i e w s h e l d w i t h each parent because they were i n c o r p o r a t e d i n t o the s o c i a l h i s t o r y d i r e c t l y . An e s t i m a t e would be s i x i n t e r v i e w s w i t h mother, one w i t h f a t h e r , and one j o i n t i n t e r view. Both parents v o i c e d i n t e r e s t i n c o n t i n u i n g w i t h the C l i n i c when procedures were e x p l a i n e d . Mrs. Davis v e r b a l i z e d concern about t e l l i n g Judy of the C l i n i c and f e l t "there was n o t h i n g t h a t Judy was concerned about a t the moment". She seemed very concerned t h a t Judy was not showi n g "penitence nor any r e g a r d f o r her wrong d o i n g s " . She r e l a t e d w e l l t o the worker, t a l k e d e a s i l y and i n t e l l i g e n t l y about the problem, and showed her main a n x i e t y i n the a r e a of b e i n g a f a i l u r e as a mother t o Judy, She grew up i n a f a m i l y of three boys and two g i r l s i n which she was the youngest s i b l i n g by t e n or twelve y e a r s . Her mother d i e d when Mrs. Davis was f i f t e e n and her s i s t e r "took over" the f a m i l y . Although the mother was "kind-hearted and happy", she was a domineering person and imposed . r e s t r i c t i o n s on her daughter which made her f e e l t h a t mother l a c k e d c o n f i d e n c e i n h e r . "Both i n r e l a t i o n s h i p w i t h her mother and s i s t e r , Mrs. Davis i d e a l i z e d t h e i r a b i l i t i e s and t r i e d to emulate them". Yet, she was t o r t u r e d by f e a r s of inadequacy and of not measuring up t o t h e i r e x p e c t a t ions of h e r . She mentioned her f a t h e r only p l a y e d a s u b s e r v i e n t r o l e i n the f a m i l y business sense. Her c h i l d h o o d memories b e i n g a b l e t o p l e a s e her mother" and of b r o t h e r s who teased her a g r e a t d e a l .  b r i e f l y , s t a t i n g t h a t he and was not a success i n a were c h i e f l y those of "not f e e l i n g " b e l i t t l e d " by her  Mr. Davis grew up i n a f a m i l y which p l a c e d success i n l i f e s o l e l y i n terms of business e n t e r p r i s e s . His f a t h e r had h i g h moral standards f o r h i m s e l f and h i s f a m i l y , and demanded hard work from h i s t h r e e sons i n the f a m i l y b u s i n e s s . One of the sons was " w i l d " and d i e d i n h i s l a t e t w e n t i e s , while another boy, next t o Mr. Davis, was h i s f a t h e r ' s f a v o u r i t e . His mother was an outspoken but understanding woman and "she made up f o r the l a c k of sympathy i n f a t h e r " , Mr, Davis i s d r i v e n to "do w e l l a t e v e r y t h i n g " and i s very i n t o l e r a n t of h i s l i m i t a t i o n s . I n view of t h i s , i t i s p o s s i b l e  t o s p e c u l a t e on the s e r i o u s impact which c o n g e n i t a l eye d e f e c t s i n both c h i l d r e n would have on him. (This was t r a c e d back t o the p a t e r n a l grandmother). T h i s prompted the D a v i s ' t o d e c i d e a g a i n s t having more c h i l d r e n . At the time o f C l i n i c c o n t a c t Mr. Davis was s u f f e r i n g from a b l o o d c o n d i t i o n f o r which he had been t r e a t e d by eminent s p e c i a l i s t s . He s t r o n g l y denied any need f o r r e s t r i c t i n g h i s activities. Mr. and Mrs. Davis appeared t o have a very compatible m a r i t a l r e l a t i o n s h i p . She, never having had c l o s e f r i e n d s , i d e a l i z e d t h i s man who l a v i s h e d so much a t t e n t i o n upon h e r . She t o l d the worker t h a t her "best endeavours do not come up to h i s worst". He, i n t u r n , f e l t t h a t h i s w i f e ' s " a t t i t u d e and understanding" made h i s success p o s s i b l e . He needed her dependency and a d m i r a t i o n . The worker' r e c o r d e d : "There i s a deep a f f e c t i o n and understanding between t h i s couple and a g r e a t dependency on each other i n t h e i r complementary a t t i t u d e s and a b i l i t i e s " . Both parents seemed to see Judy i n a detached s o r t of way - almost as i f she t h r e a t e n e d t h e i r mutual g r a t i f i c a t i o n of each other's needs. During C l i n i c c o n t a c t , Mr. and Mrs. Davis broke an appointment because they wanted t o get away f o r a h o l i d a y . T h i s seems t o have been a p a t t e r n by which Mrs. Davis escaped p e r i o d i c a l l y from the c h i l d r e n . Her s i s t e r had been l i v i n g w i t h them f o r s e v e r a l y e a r s . Mrs. Davis appeared t o t u r n t o her as a c o n t i n u i n g mother-figure f o r guidance and c o n s u l t a t i o n s c o n c e r n i n g the c h i l d r e n . At d i a g n o s t i c conference Judy was d e s c r i b e d as a g g r e s s i v e and h o s t i l e w i t h l i m i t e d s a t i s f a c t i o n s i n i n t e r - p e r s o n a l r e l a t i o n s h i p s . She i n d i c a t e d antagonism toward dominant mother f i g u r e s and saw her r o l e as t r y i n g t o outsmart the mother. She was seen as i d e n t i f y i n g with her f a t h e r because of her f e e l i n g s toward mother and because o f common a t t r i b u t e s w i t h f a t h e r such as a g g r e s s i o n and d e t e r m i n a t i o n . I t was recommended t h a t continued s e r v i c e s be g i v e n t o mother and c h i l d . "Mrs. Davis needs reassurance and support t o a l l e v i a t e her f e e l i n g of f a i l u r e w i t h Judy. Her own e f f o r t s t o emulate her competent mother and s i s t e r p l a y i n t o her f e e l i n g t h a t she should be i n c o n t r o l of Judy a t a l l times". The parents were a c c e p t i n g of the C l i n i c f i n d i n g s and s a i d that they helped t o c l a r i f y the problem. Mother agreed t o continued s e r v i c e s f o r h e r s e l f and Judy f o l l o w i n g the w a i t i n g period. When Mrs. Davis was f e l t the problem had improved a l C l i n i c h e l p . She s a i d she C l i n i c i f h e l p were needed i n Interview w i t h Mrs. was  c o n t a c t e d t h i r t e e n months l a t e r , she g r e a t l y and d i d not warrant a d d i t i o n would f e e l f r e e "to c o n t a c t the the f u t u r e " .  Davis  Mrs. Davis came t o the C l i n i c f o r the appointment. She p l e a s a n t and p a r t i c i p a t e d i n t e l l i g e n t l y i n the i n t e r v i e w . She  46 s a i d the v i s i t here had served a t w o - f o l d purpose; both t o see me and a l s o to have l u n c h w i t h a f r i e n d i n the neighborhood. I r e f e r r e d t o our telephone c o n v e r s a t i o n and her mentipniof a t t e n d i n g l e c t u r e s a t U n i v e r s i t y . She responded e n t h u s i a s t i c a l l y , d e s c r i b i n g one of her c l a s s e s - anthropology - and her i n t e r e s t i n t h a t s u b j e c t . I then t o l d her my reasons f o r seeing her - t h a t I was d o i n g a t h e s i s and t h a t the f i n d i n g s would be of s p e c i a l i n t e r e s t to the C l i n i c . I hoped t h a t she would be a b l e to focus d i r e c t l y on her r e a c t i o n s to her C l i n i c experience and I wanted her t o f e e l comfortable and t o be as f r a n k as she f e l t she c o u l d . She r e p l i e d p o s i t i v e l y , s a y i n g t h a t she would do her b e s t but t h a t she d i d n ' t have many c r i t i c i s m s t o o f f e r . I asked her t o b e g i n , i f she would, by t a l k i n g about her s a t i s f a c t i o n or d i s s a t i s f a c t i o n w i t h the C l i n i c . She f e l t she was p l e a s e d w i t h the experience and t h a t i t was v a l u a b l e not only to h e r s e l f but t o Judy and her husband as w e l l . I t was d i f f i c u l t f o r her t o h i g h l i g h t any s p e c i f i c t h i n g but she f e l t she was h e l p e d to b e t t e r understand Judy's behaviour. She thought t h a t her f e a r s of not being a b l e t o t r u s t Judy had been d i s p e l l e d . When they f i r s t came t o the C l i n i c she and Judy were not comfortable t o gether and she f e l t her daughter was not t o be t r u s t e d . Now, she has been a b l e t o r e l a x w i t h her and allow her more freedom and self-expression. We d i s c u s s e d , a t my s u g g e s t i o n , the w a i t i n g p e r i o d . She regarded i t as h i g h l y u n d e s i r a b l e - almost as though i t negated the whole problem. " I t ivas a l r i g h t w i t h us because our problem was not a s e r i o u s one". She and her husband d i d wonder why they weren't contacted f o r n e a r l y a y e a r . However, when the C l i n i c d i d c a l l they decided the problem had improved s u f f i c i e n t l y so as not "to warrant s u b j e c t i n g Judy t o the experience a l l over a g a i n " . I asked i f Judy had d i f f i c u l t y a c c e p t i n g the C l i n i c . T h i s , she s a i d , wasn't e x a c t l y what she meant. When they f i r s t brought Judy i t was d i f f i c u l t t o e x p l a i n t o her "why". They handled i t by s a y i n g i t was a good o p p o r t u n i t y "to t a l k over our problems - everybody has problems". Had t h e r e been no w a i t i n g p e r i o d Judy would have thought her- r e g u l a r C l i n i c v i s i t s as " r o u t i n e " and q u i t e "the u s u a l t h i n g " . A f t e r the wait, however, " i t j u s t wasn't worth s t a r t i n g a l l over a g a i n " . She t o l d me about coming out t o the C l i n i c a few weeks ago t o t a l k t o a gentleman about " c o n t i n u i n g " . I t was a t t h i s p a r t i c u l a r time they d e c i d e d a g a i n s t i t . I asked I f she had any p a r t i c u l a r thoughts about s e e i n g another worker ( i . e . a d i f f e r e n t worker). " I t would have been j u s t l i k e s t a r t i n g a l l over a g a i n and would have been hard on us a l l " . She l i k e d Mrs. P. so much who was a f r i e n d l y , d a i n t y l i t t l e person". I wondered about her r e a c t i o n s to the i n t e r v i e w s themselves. She admitted b e i n g "very d i s a p p o i n t e d at f i r s t " and t h i n k i n g t h a t she was g e t t i n g nowhere. She f i n a l l y d e c i d e d i t was a s i t u a t i o n which p e r m i t t e d "a c a t h a r s i s f o r the mother" and i t was then t h a t she had some " f e e l i n g " of b e i n g helped. I asked about her husband and whether or not he had been s a t i s f i e d with the C l i n i c . She thought so and "he cooperated w e l l " . She r e c a l l e d him s a y i n g , " i f the C l i n i c can h e l p us, I ' l l go and  ^7 am a l l f o r i t " . Mrs. Davis went on to e x p l a i n that she and h e r husband had been i n t e r v i e w e d " p r i v a t e l y " and she r e a l l y c o u l d n ' t e l a b o r a t e too much on h i s f e e l i n g s because she d i d n ' t know. I accepted t h i s . She wondered i f her c h i l d r e n might be g e t t i n g a very i d e a l i s t i c i m p r e s s i o n of marriage. I d i d n ' t q u i t e understand what she meant. She s t a t e d t h a t she and her husband have always got a l o n g together i n p e r f e c t harmony. The c h i l d r e n have never heard them speak a c r o s s word t o each o t h e r . Mrs. Davis expressed her f e e l i n g t h a t many problem c h i l d r e n were r e a c t i n g t o t r o u b l e or c o n f l i c t between the p a r e n t s but t h a t t h i s was j u s t not the case in their family. I asked i f Judy's problems had improved. Her "nervous m a n i f e s t a t i o n s " s t i l l p e r s i s t although they change i n form. Here, Mrs. Davis demonstrated Judy's l a t e s t h a b i t which i s a t w i t c h i n g of the nose. "She i s very h i g h s t r u n g and w i l l , I imagine, always need more guidance from us than our younger daughter". The l a t t e r , i t seems, i s more r e l a x e d and l e s s c o m p l i c a t e d . I asked about the sibling interaction. "They are sometimes l o v e a b l e , but u s u a l l y are a t each o t h e r ' s t h r o a t " . Her c h i e f worry about Judy now i s her dependence on her f r i e n d s f o r making d e c i s i o n s and s e e k i n g support. She knew some of t h i s was n a t u r a l but wondered i f Judy hadn't s t a r t e d a l i t t l e younger than most. She t h e n d e s c r i b e d a r e c e n t i n c i d e n t i n which Judy was w i l l i n g t o assume r e s p o n s i b i l i t y f o r making excuses f o r a f r i e n d t o her t e a c h e r r e g a r d i n g absence from a c l a s s . Mrs. Davis d i d not allow t h i s and t o l d Judy she must not assume these r e s p o n s i b i l i t i e s f o r o t h e r s . "Do you t h i n k I did right?" I suggested t h a t only she and Mr. Davis would know b e s t how to d e a l w i t h i n d i v i d u a l s i t u a t i o n s as they a r o s e . She accepted t h i s . She s a i d t h e r e was something which had bothered her s l i g h t l y d u r i n g her i n t e r v i e w s a t the C l i n i c . I expressed i n t e r e s t and she t o l d me of her f e e l i n g t h a t the worker l e t her " t a l k too much without d i r e c t i o n " . She f e l t as though she d i d n ' t know where she was going or what was a c t u a l l y "supposed t o happen". She f e l t perhaps she had t a l k e d a l o t and she was w o r r i e d a t the time about g i v i n g the "wrong responses". I asked i f t h i s f e e l i n g c o n t i n u e d through t o the end. She thought- i t decreased somewhat a l t h o u g h "she d i d wonder". She r e c a l l e d the i n t e r v i e w when C l i n i c f i n d i n g s were i n t e r p r e t e d . They h e l p e d her t o understand Judy b e t t e r . "Apparently, she was copying her f a t h e r more t h a n was u s u a l " . She added that t h i s s i t u a t i o n had changed a g r e a t d e a l . Judy i s now very much an E l v i s P r e s l e y f a n and i s i n t e r e s t e d i n dancing and l i k e s t o be w i t h her g i r l f r i e n d s . "They have e l e c t e d her p r e s i d e n t of one of t h e i r c l u b s " . Mrs. Davis asked suddenly i f I knew Mrs. B. I replied n e g a t i v e l y which prompted her t o e x p l a i n t h a t t h i s lady was a f r i e n d of hers who came t o the C l i n i c about the same time as Mrs. Davis was coming. T h i s lady was d i s s a t i s f i e d , f e l t she wasn't b e i n g helped and d e s i r e d t o t e r m i n a t e . A l s o , her d o c t o r . d i s approved of the C l i n i c . She asked Mrs. Davis f o r a d v i c e .  48 Mrs. Davis a d v i s e d her t o continue on the b a s i s t h a t she would n o t , f o r a time, r e a l i z e the h e l p she was g e t t i n g , but i t "was" there. "She took my a d v i c e " . Her w a i t i n g p e r i o d was not n e a r l y so l o n g as ours so we thought our problem c o u l d n ' t be as severe as t h e i r s " . I s a i d I d i d n ' t know t h e case and would be unable to e v a l u a t e i t i n terms of t h e i r s . Regarding suggestions for.Improvement, Mrs. Davis s a i d , " a l l I can t h i n k of i s what I mentioned about t h e i n t e r v i e w s " . I wondered about her f e e l i n g toward the C l i n i c p r o f e s s i o n a l team as a whole. She c o u l d n ' t r e c a l l s e e i n g any person other than the s o c i a l worker. "Oh yes - I d i d see the p s y c h i a t r i s t but she j u s t asked me a few d i r e c t q u e s t i o n s . I t wasn't r e a l l y an i n t e r v i e w " . I thanked Mrs. Davis f o r her h e l p . She f e l t she hadn't c o n t r i b u t e d much t o my study b u t she was g l a d t o do t h e b e s t she could. I m p l i c a t i o n s o f I n t e r v i e w w i t h Mrs. D a v i s . T h i s case r e p r e s e n t s an unusual s i t u a t i o n i n which the p a r e n t s , so mutually dependent upon one another, tend t o exclude the c h i l d and h e r needs from t h e i r p r i v a t e w o r l d .  Mrs. D a v i s , who  t r i e d so u n s u c c e s s f u l l y as a c h i l d t o p l e a s e h e r mother and s i s t e r , i s now, a t l a s t , a b l e t o p l e a s e someone - her husband.  He, i n  t u r n , has found i n h i s w i f e someone who understands him - who i s not only sympathetic but dependent.  Being i n t e l l i g e n t  people,  they were concerned when Judy began t o show emotional d i s t u r b a n c e s . When the s i t u a t i o n i n t e n s i f i e d they d i s c u s s e d the problem w i t h a s o c i a l worker f r i e n d and, on the b a s i s of t h i s d i s c u s s i o n ,  sought  h e l p from the C l i n i c . Mrs. Davis tended both t o negate and i n t e l l e c t u a l i z e Judy's problem, worrying more i n terms of h e r own f a i l u r e as a mother than o f Judy's unhapplness.  I n e f f e c t , by her d i s t r u s t o f  and need t o c o n t r o l Judy she was undermining h e r daughter i n much the same way as she h e r s e l f was undermined by her mother and s i s t e r . I t would appear t h a t the r e a l c o n f l i c t l a y i n the f a c t t h a t Mrs, Davis h e r s e l f d e s i r e d t o be c o n t r o l l e d r a t h e r than t o c o n t r o l . Thus, h e r husband f i l l e d t h i s need w h i l e h e r s i s t e r , who l i v e d  4-9 w i t h them, a c t e d as a mother-figure t o the c h i l d r e n . Mrs. Davis was uncomfortable  Still,  because i n terms of h e r own i d e n t -  i f i c a t i o n w i t h mother, she knew she ought t o be dominant. N e i t h e r parent c o u l d i n v o l v e h i m s e l f s u f f i c i e n t l y Judy t o continue treatment.  with  During the i n t a k e study they went on  a v a c a t i o n which n e c e s s i t a t e d the c a n c e l l a t i o n o f C l i n i c a p p o i n t ments. In  response t o the schedule Mrs. Davis s t a t e d t h a t she  was s a t i s f i e d w i t h the h e l p she r e c e i v e d from t h e C l i n i c .  She  f e l t the w a i t i n g p e r i o d was a d e t e r r e n t t o c o n t i n u a t i o n and, together w i t h reassignment,  would have made h e r f e e l as though she  were " s t a r t i n g a l l over a g a i n " . Judy's nervous m a n i f e s t a t i o n s s t i l l p e r s i s t , which i n d i c a t e s that the problem resolved. (e.g.  Mrs. D a v i s  1  has n o t been  a b i l i t y t o use p s y c h o l o g i c a l terminology  c a t h a r s i s ) demonstrates  an i n t e l l e c t u a l understanding o f  and the d e s i r e t o have been h e l p e d by her C l i n i c e x p e r i e n c e . She thought h e r C l i n i c worker was e s s e n t i a l l y h e l p f u l , a l t h o u g h she allowed h e r t o " t a l k t o o much" without p r o v i d i n g a guide-post to  i n d i c a t e "where" she was going o r "what" her responses  should  be. The w r i t e r ' s i m p r e s s i o n was t h a t Mrs. Davis never a p e r s o n a l involvement me".  felt  i n Judy's problem; "she needs guidance  from  She s t a t e s t h a t she has been a b l e t o a l l o w h e r a g r e a t e r  measure o f freedom and s e l f - e x p r e s s i o n .  T h i s , i n l i g h t of her  p e r s o n a l i t y , would seem t o i n d i c a t e something  of a r a t i o n a l e  r a t h e r than any change or m o d i f c a t i o n of h e r own a t t i t u d e s as they a f f e c t Judy. Mrs. D a v i s ' suggestions f o r improved i n c l u d e the removal  s e r v i c e s would  of b o t h the w a i t i n g p e r i o d and reassignment  50 a f t e r contact had p r o g r e s s e d .  She a l s o w o r r i e d about " f l o u n d e r i n g "  I n her i n t e r v i e w s and whether or not she t a l k e d too much or gave the " c o r r e c t " responses.  T h i s would seem t o exemplify her need  to p l e a s e r a t h e r than any r e a l involvement  w i t h the problem.  D i s c o n t i n u a t i o n would, t h e r e f o r e , seem to r e f l e c t parents  1  the  "conscious" i n t e l l e c t u a l i z e d b e l i e f t h a t they were  helped but, more deeply, p e r s o n a l growth and  suggests  a l a c k of m o t i v a t i o n toward  change.  Case No.  5 - Betty SMITH  Mrs. Smith r e f e r r e d her seven year o l d daughter B e t t y f o r h e l p a t the s u g g e s t i o n of the f a m i l y d o c t o r and a s o c i a l worker f r i e n d . She d e s c r i b e d Betty as f e e l i n g " l e f t out of t h i n g s " and d e p r i v e d of the p r i v i l e g e s enjoyed by her t w i n b r o t h e r and younger b r o t h e r , age f o u r y e a r s . Mother, a f t e r d e s c r i b i n g B e t t y ' s temper tantrums, f e l t she was not c l o s e to her daughter and t h a t both of them needed "help and a d v i c e " . A f t e r a t h r e e month i n i t i a l w a i t i n g p e r i o d Mrs. Smith phoned to say B e t t y had improved "now t h a t summer h o l i d a y s have come". She withdrew her a p p l i c a t i o n s a y i n g she would r e c o n s i d e r , i f necessary, i n the f a l l . Mr. Smith c a l l e d the C l i n i c t h r e e months l a t e r . He s t a t e d t h a t Betty was i n s e c u r e and "no one l i k e s h e r " . She a l s o r e f u s e d to go to s c h o o l . Her problems, he s a i d , were g e n e r a l l y the same as when h i s w i f e c a l l e d p r e v i o u s l y . During the d i a g n o s t i c study i n t e r v i e w s w i t h the s o c i a l worker Mrs. Smith r e v e a l e d her tendency t o i n t e l l e c t u a l i z e B e t t y ' s problems. "We have been more l e n i e n t w i t h her because she i s the l e s s favoured of the c h i l d r e n " . "I t e l l B e t t y t h a t i f I don't c h a s t i s e her f o r the t h i n g s t h a t a r e bad, other people won't l i k e h e r " . Mother thought Betty craved a f f e c t i o n , y e t c o u l d not accept it. She d i d not t h i n k c h i l d r e n c o u l d " l o v e " - they can only " l i k e " . "We are not demonstrative but we have alx<tfays p i c k e d our babies up and g i v e n them l o t s of l o v e " . Throughout, Mrs. Smith o b j e c t i v e l y v e r b a l i z e d what was wrong and what they had done as c o r r e c t i v e measures. L a c k i n g , however, was any tone o f r e a l f e e l i n g or warmth i n Mother f o r B e t t y . She i s o l a t e d B e t t y ' s problems, then a p p l i e d a p r e s c r i p t i v e treatment. She c o u l d not see why t h i s mechanical treatment d i d not produce human r e s u l t s . At the time of her l a s t i n t e r v i e w p r i o r * to d i a g n o s t i c conference Mrs. Smith came c l o s e r t o showing an understanding of the problem. T h i s was p r e c i p i t a t e d because her husband had accused her of b e i n g concerned only about B e t t y ' s anger. She s a i d ,  51 "I'm concerned about the f e e l i n g s Betty can't express — she can get as angry as she l i k e s a t me, t h a t ' s n a t u r a l , but i t i s the f e e l i n g s I n s i d e I'm concerned w i t h " . Again, however, these were 'Betty's f e e l i n g s " , and t h e r e was no awareness as to her r o l e i n c r e a t i n g the f e e l i n g s . Mr. Smith came i n a d m i t t e d l y a t h i s w i f e ' s I n s i s t e n c e . He f e l t t h a t Betty had problems but t h a t she would outgrow them. He t a l k e d about the problem areas only i n a d e s c r i p t i v e way - what Betty d i d and how he d e a l t w i t h h e r . He r e v e a l e d h i m s e l f t o have a very l i m i t e d understanding of c h i l d behaviour; "boys can be spanked and they .won't h o l d a grudge - women and g i r l s are t h i n skinned". He f i r m l y b e l i e v e d t h a t g i r l s and boys have separate needs and c h a r a c t e r i s t i c s which should not o v e r l a p . He was a "holy t e r r o r i n h i s day". But, we assume, t h i s p e r o g a t i v e belongs only to the male, hence h i s more comfortable r e l a t i o n s h i p s w i t h h i s two sons. Mrs. Smith s u f f e r e d from an i n s e c u r e , d e p r i v e d c h i l d h o o d . Her mother d i e d when she was f o u r and she spent the next f i v e years under the care of housekeepers. She was bedwetting a t s i x . At that time her f a t h e r " s u r p r i s e d " her by remarrying and r e - e s t a b l i s h i n g the home. She i n d i c a t e d f e e l i n g s of great h o s t i l i t y toward her step-mother although "she t r i e d to u n s p o i l me f o r my best w e l f a r e " . Her f a t h e r d i e d when she was f i f t e e n , l e a v i n g her " t e r r i b l y a l o n e " . She was the youngest s i b l i n g by s i x t e e n y e a r s . Her two o l d e r s i s t e r s o f t e n made her f e e l unwanted. One i s now an a l c o h o l i c and the other s u f f e r s from c h r o n i c nervous headaches. There were suggestions of m a r i t a l disharmony between Mrs. Smith and her husband. At the beginning of C l i n i c c o n t a c t she r e quested the s o c i a l worker to i n t e r v i e w them s e p a r a t e l y . At one time "he used t o be t e r r i b l y j e a l o u s and would accuse me of t e r r i b l e t h i n g s " . She f e l t h i s need was t h a t she be t o t a l l y dependent on him, which " I ' l l never be". The worker i n t e r p r e t e d Mrs. Smith as being very dependent on her husband, y e t r e b e l l i n g a g a i n s t i t . She a l s o s a i d her husband was a heavy d r i n k e r . Mother was d e s c r i b e d as b e i n g "most a c c e p t i n g " of C l i n i c a l procedures. I t would seem t h a t f a t h e r never became i n v o l v e d enough to d i s c u s s the purpose and f u n c t i o n of the C l i n i c . Mother's a f f e c t was "calm" - her speech was " r e s e r v e d l y spontaneous". Father had an off-hand manner, and u n s u c c e s s f u l l y t r i e d to appear c a s u a l and comfortable. He would only consent t o one i n t e r v i e w . Betty was brought t o the C l i n i c by her mother who i n t e r p r e t e d the v i s i t as a means of f i n d i n g out "why they got so c r o s s a t each o t h e r " . Team f i n d i n g s r e v e a l e d B e t t y to be i n s e c u r e and unhappy. She had extreme f e a r s of b e i n g l e f t by her parents and f e l t she c o u l d not p l e a s e them. I t was f e l t t h a t Mrs. Smith's unresolved h o s t i l i t y toward her step-mother and jfemale s i b l i n g s was d i s t o r t i n g her r e l a t i o n s h i p w i t h B e t t y . The c h i l d was a l s o being s u b j e c t e d t o her f a t h e r ' s h o s t i l i t y t o a l l women. Continued s e r v i c e was recommended f o r Mother and B e t t y w i t h an e f f o r t to e n l i s t Father's p a r t i c i p a t i o n .  52 C l i n i c f i n d i n g s were i n t e r p r e t e d t o the parents t o g e t h e r . Mother was c r i t i c a l of F a t h e r and accused him, b e f o r e the worker, f o r not c o o p e r a t i n g i n h e r e f f o r t s t o h e l p B e t t y . The w a i t i n g p e r i o d was e x p l a i n e d and both parents i n d i c a t e d a d e s i r e f o r c o n t i n u e d services. Mrs. Smith d e c l i n e d the o f f e r of continued s e r v i c e s a f t e r an e i g h t month w a i t i n g p e r i o d . "Betty i s much b e t t e r and i t h e l p e d to t a l k over our d i f f i c u l t i e s at the C l i n i c . " Telephone C o n v e r s a t i o n I c a l l e d Mrs. Smith mentioning that the C l i n i c had d i s p a t c h e d a l e t t e r t o h e r yesterday and "wondered i f she had r e c e i v e d i t . She t o l d me i t came t h i s morning and she would c e r t a i n l y be agreeable to me coming t o the house f o r an i n t e r v i e w only she was a f r a i d she d i d n ' t have any " c o n s t r u c t i v e c r i t i c i s m s " t o o f f e r . She was p l e a s e d w i t h the h e l p she had r e c e i v e d and t h a t was about a l l she c o u l d s a y . I s a i d I'd be i n t e r e s t e d t o hear about how she was helped and t h a t she wasn't n e c e s s a r i l y c o n f i n e d t o s t a t i n g c r i t i c i s m s . She thought i t would be f i n e f o r me to come and asked what days I was a l l o t i n g to t h i s p a r t of my work. She suggested I come Tuesday a f t e r n o o n next at 2 o ' c l o c k . Comment: Mrs. Smith spoke i n t e l l i g e n t l y about the purpose of my visit. I thought she seemed p l e a s e d t h a t she was t o be i n c l u d e d i n the study and there were no i n d i c a t i o n s of a n x i e t y or r e s i s t a n c e . I n t e r v i e w w i t h Mrs. Smith Mrs. Smith g r e e t e d me p l e a s a n t l y . Throughout she was f r i e n d l y and spontaneous and seemed t o enjoy our c o n v e r s a t i o n . I d i d n o t sense t h a t she f e l t i n any way anxious or d i s t u r b e d by my visit. We spoke o f p l e a s a n t r i e s a t f i r s t _ — then I mentioned my purpose i n coming and hoped I had made myself e x p l i c i t i n our telephone c o n v e r s a t i o n . She smiled, s a y i n g t h a t she understood what I was attempting t o f i n d out and hoped she c o u l d h e l p . She was very p l e a s e d with the C l i n i c s e r v i c e s to the p o i n t at which she withdrew. I t was j u s t what she needed — "you know, i t was Mother therapy more than C h i l d . " She thought h e r worker was a r e a l " p r o f e s s i o n a l l i s t e n e r " who h e l p e d her t o look a t her problems and do something about them. Mr. Smith only came f o r one i n t e r v i e w 'and he never would admit i t helped, but i t must have a t l e a s t s t a r t e d him t h i n k i n g . " She e x p l a i n e d her husband's a v e r s i o n to a n y t h i n g " p s y c h i a t r i c " s i n c e t h e time he was removed from combat by the army d u r i n g the war. She supposed the new C l i n i c was a g r e a t improvement. I wondered what thoughts she had around t h i s . She has not seen i t but the o l d b u i l d i n g , where she and B e t t y had gone was c e r t a i n l y not a t t r a c t i v e — e s p e c i a l l y the f i r s t time or two. She thought i t would make a great d i f f e r e n c e t o people who come t o a C l i n i c that r e a l l y looks l i k e a C l i n i c .  53 I mentioned her withdrawal f o l l o w i n g the w a i t i n g p e r i o d and wondered' i f the two were connected. Mrs. Smith thought f o r q u i t e some time, then s a i d "yes, I suppose they were; but the wait wasn't a bad t h i n g f o r us. I wasn't q u i t e sure that I understood. She proceeded slowly: "I used the w a i t i n g p e r i o d to t h i n k about what had been going on d u r i n g my C l i n i c i n t e r v i e w s . " "Although i t was my i n t e n t i o n to r e t u r n to the C l i n i c I d i s c o v e r e d , w h i l e w a i t i n g , that I c o u l d manage without f u r t h e r h e l p . " She f e l t her improved r e l a t i o n s h i p s with Mr. Smith and B e t t y began t o take r e a l form a t t h i s time. She a g a i n mentioned the worker and d e s c r i b e d her i n terms of an " e x c e l l e n t caseworker", a s k i n g me i f she were u s i n g the c o r r e c t t e r m i n o l o g y . I asked Mrs. Smith i f she were aware t h a t , had she r e t u r n e d to the C l i n i c , a d i f f e r e n t worker would have seen h e r . "Yes — she was t o l d something about t h i s . " She expressed doubts about the d e s i r a b i l i t y of t h i s procedure, t h i n k i n g i t would be b e s t i f the same worker c o n t i n u e d with the c a s e . She thought, however, that we might f i n d i t h e l p f u l to get another worker's o p i n i o n o f the case. I s a i d we t r i e d t o accomplish t h i s w i t h the m u l t i d i s c i p l i n e d or team approach. This s t a r t e d her t h i n k i n g and she expressed d i s s a t i s f a c t i o n about her c o n t a c t w i t h the p s y c h i a t r i s t . "I only saw him f o r f i v e minutes and I c o u l d n ' t t e l l him a n y t h i n g i n t h a t time." She remembered f e e l i n g very "cheated" a t the time. She had a l s o wondered what the p s y c h i a t r i s t had s a i d to B e t t y . "He must have calmed her t r o u b l e s and answered her q u e s t i o n s because she d i d n ' t ask me a n y t h i n g a f t e r w a r d about why I had taken her." I asked i f B e t t y ' s problems had changed s i n c e the C l i n i c c o n t a c t . "She i s no t r o u b l e at a l l now; she gets c r o s s at me and says e x a c t l y what i s b o t h e r i n g her and I know where I stand." She used to brood and sulk but t h i s has a l l changed. I wondered i f Mrs. Smith a t t r i b u t e d t h i s change to any s p e c i f i c t h i n g . She thought i t was due p a r t l y to her age but mostly because "we've a l l changed." The most h e l p f u l aspect of her C l i n i c experience was b e i n g allowed "to get t h i n g s o f f my c h e s t . A f t e r the f i r s t two i n t e r v i e w s I was d i s a p p o i n t e d and cross — I f e l t I wasn't g e t t i n g any h e l p a t a l l . Then-, as time went on I r e a l i z e d the worker was h e l p i n g me t o l o o k at my own problems so I_ c o u l d do something about them." I s a i d she had, i n essence, a l r e a d y answered my next q u e s t i o n which was whether or not the C l i n i c had conveyed the need f o r parent p a r t i c i p a t i o n as w e l l as c h i l d . She thought t h i s was something she r e a l i z e d g r a d u a l l y as the i n t e r v i e w s p r o g r e s s e d . "In my case Mother needed h e l p so t h a t C h i l d c o u l d be helped." She wished her husband had cooperated more. He had, however, ceased i n h i s v e r b a l o b j e c t i o n s to the C l i n i c a f t e r h i s one i n t e r v i e w . I wondered how and i n what ways she thought the C l i n i c might improve i t s s e r v i c e s . "That's a hard one." She thought I might get more h e l p w i t h t h i s from people who had come to the C l i n i c w i t h more severe problems than they had e x p e r i e n c e d . She saw t h e i r problem as one which was ready t o be h e l p e d . She suggested t h a t the C l i n i c c o u l d do a g r e a t e r s e r v i c e to the community by " t a l k i n g i t s e l f up and by e x p l a i n i n g what i t does f o r parents and c h i l d r e n . " She has t o l d many of her f r i e n d s a l l about the C l i n i c . Most of them knew l i t t l e or n o t h i n g about i t . One person asked i f the s o c i a l  5k workers there had g i v e n her the "run around" because they d i d a t the agency i n Vancouver. Mrs. Smith s a i d she q u i c k l y r e c t i f i e d t h i s misconception. I thanked her f o r b e i n g so c o o p e r a t i v e w i t h me. She hoped she had been of some help but f e l t her " c o n s t r u c t i v e c r i t i c i s m s " were few and f a r between. I m p l i c a t i o n s of the Interview w i t h Mrs.  Smith  I n the Smith case we are c o n f r o n t e d with something of an anomalous s i t u a t i o n .  The case a n a l y s i s shows a d e p r i v e d mother  who,  never having a c h i e v e d f e e l i n g s of worth and adequacy as a woman, i s unable to t r a n s m i t these c h a r a c t e r i s t i c s to her daughter. one way  Freud's  c l a s s i c a l c l i n i c p i c t u r e of "penis-envy"  suggested as we  v i s u a l i z e mother and daughter  a sense of i d e n t i t y with t h e i r own We  might be  s t r u g g l i n g to a t t a i n  sex.  must p o s t u l a t e , however, t h a t the problem was  severe as the r e c o r d would suggest.  In  not  The worker, a p p a r e n t l y ,  so  was  not only a b l e t o f e e l the need but a l s o t o meet i t w i t h the appropr i a t e l e v e l of casework.  A note of concern r i s e s  i n the f a c t t h a t  nowhere i n the r e c o r d i n g has the worker i n t i m a t e d ~ t h e s i g n i f i c a n t movement which the w r i t e r ' s i n t e r v i e w suggests took p l a c e .  This  h i g h l i g h t s another p o i n t , which i s the l a c k of a d i a g n o s t i c h y p o t h e s i s or statement  upon which the worker operated both to e x p l o r e the  of the case and t o formulate her casework  facts  approach.  With these thoughts b e f o r e us we must accept the i n t e r v i e w w i t h Mrs. Smith at f a c e value t o g e t h e r with i t s i m p l i c a t i o n s . was  She  completely s a t i s f i e d with the C l i n i c s e r v i c e s to the p o i n t a t  which she withdrew. help offered.  She was  a b l e to r e c o g n i z e and make use of the  The w a i t i n g p e r i o d , although a f a c t o r i n her  t o withdraw, was  decision  u t i l i z e d c o n s t r u c t i v e l y as a p e r i o d of c r y s t a l l i z a t i o n  i n which Mrs. Smith m o b i l i z e d her i n n e r r e s o u r c e s on the s t r e n g t h of the casework h e l p a l r e a d y r e c e i v e d .  She  doubtless would have continued  55 f o r a longer p e r i o d i n treatment  had there been no w a i t i n g p e r i o d .  F o r t u n a t e l y , however, she had been h e l p e d t o the degree t h a t she • was able t o c a r r y on comfortably without  additional Clinic services.  B e t t y ' s problem i s much improved, a f a c t which h e r mother a t t r i b u t e d t o the C l i n i c ' s s e r v i c e s . process  She r e c o g n i z e d i t as an i n d i r e c t  d u r i n g which she was helped t o examine and work through h e r  own d i f f i c u l t i e s , and Mr. Smith.  thus d i m i n i s h i n g h e r need t o f i n d f a u l t w i t h B e t t y  This i n t u r n r e l i e v e d much o f the t e n s i o n i n them  and t h e i r r e l a t i o n s h i p s improved with strengthened  f e e l i n g s o f good  w i l l and understanding. The w r i t e r would a l e r t the reader to the same f l a v o u r o f i n t e l l e c t u a l i z a t i o n by mother i n the i n t e r v i e w as permeates the case analysis.  I t i s almost as though she had i n c o r p o r a t e d e x a c t l y what  the worker had s a i d .  We might a l s o s p e c u l a t e t h a t the s o c i a l worker  f r i e n d who was i n s t r u m e n t a l i n the r e f e r r a l , was a l s o , i n some degree, r e s p o n s i b l e f o r the mother's s u c c i n c t e x p l a n a t i o n (and understanding) of what t r a n s p i r e d w i t h i n h e r s e l f as a r e s u l t o f h e r C l i n i c Mrs.  Smith's only c r i t i c i s m was her b r i e f contact w i t h the  p s y c h i a t r i s t which, t o some c l i e n t s , event  contact.  of the C l i n i c The reasons  seems t o r e p r e s e n t the f o c a l  experience. f o r d i s c o n t i n u a t i o n i n t h i s case would seem  to be t h a t e i t h e r continued h e l p was r e c e i v e d from another  source,  t h a t i s , t h e s o c i a l worker f r i e n d who was i n s t r u m e n t a l i n the r e f e r r a l ; or, that the case was erroneously diagnosed  as r e q u i r i n g c o n t i n u e d  casework s e r v i c e s when only a " b r i e f s e r v i c e " c o n t a c t was  necessary.  56 Was the C l i n i c H e l p f u l ? The reader, having been f r e s h l y i n t r o d u c e d t o the f i v e cases w i l l perhaps f i n d i t both a p p r o p r i a t e and i n t e r e s t i n g i f a c o l l e c t i v e assessment i s now made of the a c t u a l h e l p by the C l i n i c .  enabled  I t i s the w r i t e r ' s o p i n i o n that one was helped,  w h i l e four were n o t . In  the follow-up i n t e r v i e w s the Mrs. Anderson,  and Cook were openly n e g a t i v e and h o s t i l e toward t h e i r experience.  Bennett,  Clinic  There was almost a complete l a c k o f i n s i g h t  into  e i t h e r the purpose or the nature of t h e i r r e l a t i o n s h i p s w i t h the worker.  T h i s , t o g e t h e r w i t h t h e i r c o n t e n t i o n s that the problems  were unchanged, (or, i f some improvement had o c c u r r e d i t was the r e s u l t o f the mothers' endeavours),  would seem t o s u b s t a n t i a t e  the w r i t e r ' s assessment t h a t C l i n i c h e l p was n e i t h e r r e a l i z e d nor used i n the three c a s e s . Mrs. Davis was able t o g i v e an i n t e l l e c t u a l i z e d ment t h a t h e l p was r e c e i v e d .  state-  There a r e i n d i c a t i o n s , hoivever,  t h a t the r e f e r r i n g problem has not changed a p p r e c i a b l y . F o r example, Mrs. Davis s a i d t h a t Judy's nervous mannerisms have not disappeared. Secondly,  Instead, t h e r e are now a g r e a t e r v a r i e t y of them.  i n the i n t e r v i e w she proudly d e s c r i b e d the i d e a l  which she and her husband a r e e x p e r i e n c i n g .  T h i s , the reader  w i l l r e c a l l , was noted w i t h some concern by the o r i g i n a l worker who f e l t  marriage  case  that Mr. and Mrs. Davis were so dependent upon  each other t h a t Judy f e l t h e r s e l f t o be p l a y i n g the r o l e o f an intruder.  At the present Mrs. Davis i s w o r r i e d because Judy i s  "more than  'normally' dependent upon h e r f r i e n d s " .  Such a  s i t u a t i o n would seem t o be a l o g i c a l recourse f o r Judy when her own needs a r e excluded by the n e u r o t i c interdependency  of her  57 parents.  Thus, i t would appear t h a t , i n essence, Judy's  problem was not helped a t the C l i n i c . The  Smith case, as a l r e a d y  i n d i c a t e d , seems t o be one  i n which the mother was able t o use the b r i e f C l i n i c  contact  p o s i t i v e l y t o examine and work through h e r own d i f f i c u l t i e s , thereby  d e c r e a s i n g h e r need t o w i t h h o l d warmth and l o v e from  Betty.  According  therapeutic. particular  t o Mrs. Smith even t h e w a i t i n g - p e r i o d was  There was no i n d i c a t i o n  casework technique  i n the case r e c o r d t h a t a  was used by t h e worker t o help Mrs.  Smith use the w a i t i n g - p e r i o d b e n e f i c i a l l y .  B e t t y ' s problem has  improved a p p r e c i a b l y which her mother a t t r i b u t e d therapy"  t o "mother-  a t the C l i n i c .  The  cases t o t h i s p o i n t have been d i s c u s s e d  w i t h the emphasis on t h e i r i n d i v i d u a l  separately  i m p l i c a t i o n s f o r the study.  I n Chapter Three an attempt w i l l be made to l o c a t e p a t t e r n s or responses which are common t o t h e case-summaries and to the follow-up  i n t e r v i e w s as a whole.  CHAPTER I I I The. Common Denominator In  t h i s chapter an assessment w i l l be made of the case  s t u d i e s as a whole t o r e v e a l patterns-, i n d i c a t o r s , or c h a r a c t e r i s t i c s which a r e common to two or more o f the f i v e cases; and which might have p r o g n o s t i c value i n determining cases t h a t a r e likely  t o d i s c o n t i n u e treatment. The s e c o n d . p o r t i o n of the chapter w i l l d e a l w i t h mat-  e r i a l o b t a i n e d i n the f i v e follow-up i n t e r v i e w s which the c l i e n t s c o n s c i o u s l y r e c o g n i z e as b e i n g the causes o f t h e i r  withdrawal.  The v a l i d i t y of t h i s m a t e r i a l as w e l l as i t s i m p l i c a t i o n s f o r the study w i l l be d i s c u s s e d . "Withdrawal I n d i c a t o r s " (1)  The K i n d o f R e f e r r a l It  seems of i n t e r e s t to t h i s study t h a t p r o f e s s i o n a l  people were i n v o l v e d i n f i v e o f the r e f e r r a l s .  Both Mrs. Smith  and Mrs. Davis c o n s u l t e d s o c i a l worker f r i e n d s b e f o r e coming t o the C l i n i c .  An attempt  w i l l t h e r e f o r e be made t o assess the  r o l e o f these workers i n r e l a t i o n t o the problems of t h e i r S o c i a l workers g e n e r a l l y accept the statement  friends.  that  c l i e n t s must experience a p a r t i c u l a r c r i s i s or r e a c h a c e r t a i n i n t e n s i t y of a n x i e t y b e f o r e they a r e m o b i l i z e d t o seek h e l p .  A  r e l a t i o n s h i p begins t o form when the problem i s shared w i t h a worker.  This,. I n t u r n , u s u a l l y s t i m u l a t e s some emotional i n -  volvement of the c l i e n t which the worker c a n u t i l i z e  i nhelping  h e r t o some awareness of her c o n t r i b u t i o n t o t h e problem; ( i n Clinic  cases, the c h i l d ' s  problem).  59 I f however, t h e c l i e n t  (parent) d i s c u s s e s the s i t -  u a t i o n w i t h a s o c i a l worker p r i o r t o r e f e r r a l , i t seems r e a s o n a b l e t h a t much o f the emotional involvement may remain a t t a c h e d to  the f r i e n d from and w i t h whom h e l p was f i r s t  ings v e n t i l a t e d .  sought and f e e l -  Thus, i n accordance w i t h the theory o f t r a n s -  f e r e n c e , the parent would c o n c e i v a b l y come t o an agency ( i n t h i s case, the C l i n i c ) to p l e a s e t h e f r i e n d . to  experience the C l i n i c r e l a t i o n s h i p more on a s u p e r f i c i a l  level. of  T h i s would enable h e r  She might be f r e e t o i n t e l l e c t u a l i z e a n understanding  h e l p she was g e t t i n g but, a t t h e same time, e s s e n t i a l l y r e -  main u n i n v o l v e d and so be a b l e t o i\rithdraw a t an a p p r o p r i a t e time t h i n k i n g she had been h e l p e d .  By t h i n k i n g she was h e l p e d  the c l i e n t would be g i v i n g p l e a s u r e t o t h e o r i g i n a l person (the p r o f e s s i o n a l f r i e n d ) t o whom the problem-evoked t r a n s f e r e n c e elements  were s t i l l  attached.  While b o t h Mrs. Smith and Mrs. Davis d i d not come back to  the C l i n i c t h e r e i s some evidence from the i n t e r v i e w s t h a t  they had r e c e i v e d help, to understand t h e i r problem two  friends.  from  their  T h i s , i n f a c t , might have been the "continued h e l p "  which the C l i n i c o f f e r e d but which t h e two mothers d e c l i n e d on, the b a s i s t h a t they had a l r e a d y been h e l p e d  sufficiently  0  The other t h r e e cases s t u d i e d were r e f e r r e d by d o c t o r s i  who  might c o n c e i v a b l y p l a y a s i m i l a r r o l e t o t h a t o f t h e s o c i a l  worker f r i e n d s d e s c r i b e d above.  I t would perhaps  be a d v i s a b l e  i n the f u t u r e f o r C l i n i c workers t o be on the a l e r t f o r cases which are r e f e r r e d by o r i n which there have been p r e v i o u s cont a c t s w i t h p r o f e s s i o n a l persons w i t h whom the c l i e n t s have d i s cussed t h e i r problems.  I t may be necessary i n such cases t o  6o i n v o l v e the c l i e n t i n a d i s c u s s i o n of her r e l a t i o n s h i p w i t h the r e f e r r a l person.  T h i s would h e l p the c l i e n t to assess the  u a t i o n more on a r e a l i t y l e v e l , w h i l e the Involvement  sit-  would en-  courage a t r a n s f e r of her f e e l i n g s from the r e f e r r a l p e r s o n t o the worker. I t i s suggested,  t h e r e f o r e , that r e f e r r a l sources  may  be i n d i c a t o r s of withdrawal and that C l i n i c workers should be aware of t h e i r s i g n i f i c a n t r a m i f i c a t i o n s .  T h i s would r e q u i r e  f u r t h e r study i n i t s e l f to e s t a b l i s h i t s r e l i a b i l i t y as a p r e dictive (a).  Who  tool. Brought  the C h i l d  I n the cases s t u d i e d the l a c k of f a t h e r - p a r t i c i p a t i o n i n the C l i n i c experience of mother and c h i l d i s i m p r e s s i v e . Anderson was  d e s c r i b e d as " c o - o p e r a t i v e but unenthused" and  thought h i s w i f e was  exaggerating B i l l y ' s problems.  he  Mr. Cook d i d  not come f o r an i n t e r v i e w p r i o r to the completion of the history.  :Mr.  social  Mr. Smith admitted coming a t h i s w i f e ' s i n s i s t e n c e ,  w h i l e Mr. Davis was the l a t t e r was  probably seen only twice i n a l l .  The need o f  t o p l a c a t e h i s w i f e which would not suggest  any  r e a l involvement with the C l i n i c . T h i s l a c k of support from the husband would appear t o be a d e v a l u i n g s i t u a t i o n f o r the mother and tends t o c r e a t e i n her a f e e l i n g t h a t she i s c a r r y i n g the r e s p o n s i b i l i t y a l o n e .  It  i s acknowledged t h a t t h i s . l a c k of f a t h e r - p a r t i c i p a t i o n p r o b a b l y appears a l s o i n cases which c o n t i n u e through treatment.  However,  the s i t u a t i o n would p o s s i b l y be most harmful when the mother h e r s e l f has a s t r o n g r e s i s t a n c e to treatment.  A n e g a t i v e or d i s -  i n t e r e s t e d response from the f a t h e r would t h e r e f o r e tend to d i s courage the mother and might, i n these cases, be p r e d i c t i v e o f withdrawal.  61 (3)  Sex o f the  Child  I t i s i n t e r e s t i n g t h a t i n a l l o f the cases  studied  the mothers had u n r e s o l v e d h o s t i l i t y toward the parent same sex as the c h i l d d i s p l a y i n g the b e h a v i o u r a l Mrs. Anderson admitted  of the  disturbances.  h a t i n g her f a t h e r , but remarked about h i s  affection for B i l l y . While Mrs. Bgnnett admired her f a t h e r ' s i n t e l l e c t , i t would appear t h a t she was c o m p e t i t i v e l y d r i v e n t o be h i s which c r e a t e d angry, h o s t i l e f e e l i n g s although, enhanced her  status.  She married  whom she c o u l d manipulate.  l a r g e extent,  a t t h e same time,  an i n t e l l e c t u a l l y i n f e r i o r man  Thus, L a r r y ' s s t r o n g w i l l and super-  i o r i n t e l l e c t both f r u s t r a t e and t h r e a t e n Mrs.  her.  Cook's h o s t i l i t y t o h e r f a t h e r must be, surmised.  equal  to a  I t does, however, seem s i g n i f i c a n t t h a t  she a l l b u t denied h i s e x i s t e n c e .  Her e n t i r e c h i l d h o o d  centered  around mother t o whom she was s t i l l  dependently t i e d a t t h e  time she was coming t o t h e C l i n i c .  She d i d v o i c e anger toward  her b r o t h e r who was "strange" and "could not make f r i e n d s " . Jimmy, she s a i d , had t h e same d i f f i c u l t i e s . Mrs.  Smith's mother d i e d when she was f i v e .  c l e a r p i c t u r e o f her growing up without  i d e n t i f i c a t i o n , angry  at h e r mother f o r " l e a v i n g " her, and b i t t e r toward her mother who " u n s p o i l e d me f o r my best w e l f a r e " . we see Mrs.  We g e t a  step-  Understandably,  Smith unable t o communicate a f e e l i n g o f warmth and  identity to Betty. Mrs. adolescence sister.  Davis v i v i d l y r e c a l l e d spending her c h i l d h o o d and  t r y i n g u n s u c c e s s f u l l y t o p l e a s e h e r mother and o l d e r  She was f r u s t r a t e d by f e a r s o f Inadequacy and a sense  62 of b e i n g alone a g a i n s t a domineering Davis has attempted and has succeeded  mother and s i s t e r .  Mrs.  t o emulate her mother's p a t t e r n w i t h Judy  i n c r e a t i n g i n her s i m i l a r f e e l i n g s to those  she experienced as a c h i l d .  I n her t u r n , Judy, i s now  "antag-  o n i s t i c t o dominant mother f i g u r e s " . I t i s not w i t h i n the scope of t h i s study t o p r e s e n t a t h e o r e t i c a l e x p o s i t i o n o f the dynamics operating.,in these Rather, the w r i t e r ' s purpose i s merely  cases.  to i d e n t i f y , where pos-  s i b l e , p a t t e r n s common to a m a j o r i t y of the c a s e s .  The under-  l y i n g dynamic p a t t e r n d e s c r i b e d above would seem to suggest displacement  of the h o s t i l i t y f e l t by the mother twoard her  parent on t o one I t may  a "bad"  of her c h i l d r e n of the same sex as the p a r e n t . be p r o g n o s t i c a l l v v a l u a b l e , t h e r e f o r e  workers t o r e c o g n i z e cases i n which the mother has  r  for  unresolved  h o s t i l i t y toward the parent of the same sex as the child.-whom she b r i n g s f o r C l i n i c a l (4)  examination.  Parents Responses t o the Problem An examination of the p a r e n t s ' responses  problems was  thought  to be worthwhile  to the c h i l d ' s  i n terms of e s t a b l i s h i n g a  'pattern-response' which might a l e r t workers i n f u t u r e cases t o the p o s s i b i l i t y of w i t h d r a w a l . Mrs. Anderson regarded B i l l y ' s problem as a h o s t i l e a t t a c k upon h e r s e l f .  Her response was  m a i n t a i n her status-quo.  t o f i g h t back i n order t o  Unc.oncsciously, i t were as though she  had to j u s t i f y her r e j e c t i o n of B i l l y by making him a c t o u t . L a r r y ' s b e h a v i o u r a l problems prompted Mrs. Bennett push him away - open r e j e c t i o n . him t h a t h i s behaviour was  T h i s was  to  her method of showing  unacceptable t o h e r .  Both parents  s t r e s s e d c o n f o r m i t y and t r i e d v a r i o u s d i s c i p l i n a r y  approaches,  6 hoping one would  1  3  fit • 1  Mrs. Cook saw Jimmy's problem as an endurance t e s t f o r her  and w o r r i e d about what others might t h i n k .  Her complete i n -  a b i l i t y to cope i s summed up i n her statement: "When he was  a  baby I t r i e d to love him when he was bad; as a l i t t l e boy I t r i e d t o t a l k him out o f i t ; now  I t e l l him to shut-up".  Mrs. Davis* response was  l a r g e l y a n x i e t y about  falling  as a mother and concern t h a t Judy d i d not show "penitence nor any regard f o r her wrong d o i n g s " . of  Both p a r e n t s sought some way  responding to Judy which would s a t i s f y her, and yet not en-  c r o a c h on t h e i r mutual  dependence.  B e t t y Smith caused her mother t o f e a r the o p i n i o n s of others i n r e g a r d to her daughter's problems.  T h i s , o f course,  meant f e a r l e s t they might seem to be a r e f l e c t i o n on h e r s e l f . P a r e n t a l responses were i n terms of a p r e c o n c e i v e d p r e s c r i p t i v e treatment which would, h o p e f u l l y , cure the problem. While i t i s d i f f i c u l t t o suggest a d e f i n i t e  'common  response  1  i n the f i v e c a s e s , there does seem t o be a s i g n i f i c a n t  trend.  The f i v e mothers responded as though the c h i l d ' s  i o u r problems were a t h r e a t to themselves. ied  behav-  These responses v a r -  from f e a r s as t o what other people might t h i n k , t o overt  h o s t i l i t y wherein the mother f e l t compelled t o compete w i t h the c h i l d f o r mastery i n order to p r e s e r v e her own c o n t r o l l i n g , omnipotent p a r e n t .  s e l f - i m a g e as the  These responses seem t o suggest  both an i n s e c u r i t y o f mother-role and a b a s i c l a c k of s e l f - w o r t h . It the  may  be t h a t withdrawal Is imminent  i n cases where  mother expresses more concern f o r h e r s e l f t h a n f o r the c h i l d  and where she a l i g n s h e r s e l f a g a i n s t him and responds t o h i s problems i n a manner which protects her from h e r s e l f and from the  -64 c r i t i c a l opinions (5)  Parents' It  of o t h e r s .  Concept o f the Problem i s the w r i t e r ' s o p i n i o n t h a t the p a r e n t s '  o f the c h i l d ' s problem w i l l perhaps p r o v i d e  concept  some of the most  sig-  n i f i c a n t f a c t o r s i n t h i s study which may be p r e d i c t i v e of d i s continuation.  One a r e a which might be c o n s i d e r e d  i s t h a t o f aware-  ness on the p a r t o f the parents as to whether o r not they a r e p l a y i n g a r o l e i n the problem. An examination o f the f i v e cases s t u d i e d f a i l e d t o p r o v i d e any i n d i c a t i o n s that such awareness e x i s t e d . f l e e t i n g references venience:  There were two  which a r e now r e c a l l e d f o r the reader's con-  Mrs. Anderson s a i d a t one p o i n t ,  "I wonder what I am  doing t o B i l l y " ; w h i l e the Bennetts v e r b a l i z e d t h e b e l i e f  that  "a c h i l d ' s behaviour stems from the treatment he r e c e i v e s " .  The  worker d i d not p i c k these up f o r d i s c u s s i o n which might have l e d to an e x p l o r a t i o n o f f e e l i n g s and some i n s i g h t f o r the parents as t o t h e i r c o n t r i b u t i o n i n c r e a t i n g the problem s i t u a t i o n s . The  interviews  flavoured with parental  i n the f i v e case r e c o r d s  i n t e l l e c t u a l l z a t i o n which u s u a l l y  c a t e s or suggests a r e s i s t a n c e t o p e r s o n a l any  were h i g h l y  involvement.  indiWithout  r e a l Involvement p a r e n t a l a n x i e t y would soon decrease and  could provide  a basis f o r withdrawal.  Such i n t e l l e c t u a l i z a t i o n ,  i n c l u d i n g the usage o f p s y c h o l o g i c a l terminology, would seem t o be a defence mechanism by which the parent detaches h i m s e l f  from  the r e a l problem, thus a v o i d i n g any involvement which might expose h i s true f e e l i n g s . The  w r i t e r p o s t u l a t e s , t h e r e f o r e , t h a t parents who  have an i n t e l l e c t u a l approach t o the c h i l d ' s problem may have-a marked tendency t o withdraw.  T h i s c o u l d be due e i t h e r t o a  65 decrease  i n a n x i e t y w i t h no r e a l involvement, or, as Gordon  Hamilton suggests: "In cases where mothers do not i n d i c a t e a t the outset some awareness that they are p l a y i n g a r o l e i n the c h i l d ' s d i f f i c u l t y , when t h i s i s r e c o g n i z e d , f i n a l l y , the mother may  be thrown i n t o a p a n i c and withdraw because  of g u i l t , u n l e s s  1 very c a r e f u l l y handled." There was  a l s o a n o t i c e a b l e p a t t e r n i n the f i v e cases  where one of the parents e i t h e r underestimated the c h i l d ' s lem or v e r b a l i z e d a b e l i e f that the problem had changed. Anderson, blems";  probMr.  f o r example, "thought h i s w i f e exaggerated B i l l y ' s p r o -  Mr. Cook was  "somewhat opposed to the C l i n i c ,  feeling  t h a t h i s w i f e i s exaggerating her t r o u b l e s w i t h Jimmy"; Davis s a i d ,  "there was  n o t h i n g t h a t Judy was  Mrs.  concerned about at  the moment"; Mrs. Smith withdrew a f t e r B e t t y ' s f i r s t  referral  b e f o r e the C l i n i c had seen her s a y i n g t h a t she had improved. the second r e f e r r a l Mr. Smith contended t h a t "Betty had  After  problems  but she would outgrow them". T h i s p a t t e r n would seem to v e r i f y Guise's f i n d i n g s t h a t many "parents who withdrew tend to underestimate the c h i l d ' s problem, c l a i m i n g e i t h e r t h a t i t i s not a problem or t h a t i t has  2  diminished." (6)  P a r e n t s ' R e a c t i o n s to C l i n i c F i n d i n g s An examination of the p a r e n t s ' r e a c t i o n s t o C l i n i c  1 Hamilton, Gordon, Psychotherapy  op. C i t . , pp. 281-82 2  i n Child  Guidance,  ... ; :  ?  Guise, Jane, Withdrawal and C o n t i n u a t i o n I n a C h i l d Guidance C l i n i c . T h e s i s A b s t r a c t i n Smith C o l l e g e Studied i n Soci a l Work, P u b l i s h e d by Smith C o l l e g e School f o r S o c i a l Work, Northampton, Mass., V o l . X X I I I , Oct., 1952-June,1953, PP« 1 7 3 - 4 .  66 f i n d i n g s was  thought t o be p e r t i n e n t to t h i s study and t o have  some p r e d i c t i v e s i g n i f i c a n c e .  They w i l l now  be examined t o de-  termine whether or not they can c o n t r i b u t e to p r e d i c t i o n about withdrawal from  treatment.  Mrs. Anderson was  " r e s t r a i n e d and anxious" w h i l e the  worker I n t e r p r e t e d the r e s u l t s of the d i a g n o s t i c c o n f e r e n c e . She asked "what was  meant by treatment and expressed doubt  she c o u l d ever behave d i f f e r e n t l y toward  Billy".  When C l i n i c f i n d i n g s were e x p l a i n e d t o Mrs. she "wrote e v e r y t h i n g down, was  that  Bennett  apprehensive of 'treatment',  and  expressed concern about her own r o l e i n i t . " Mrs. Cook showed l i t t l e Clinic findings. to  or no a p p r e c i a t i o n of t h e  She tended to evade the i s s u e s by attempting  draw the worker i n t o a d i s c u s s i o n of her own poor h e a l t h .  f e l t a change i n her a b i l i t y to h e l p and understand Jimmy  She  was  dependent upon the success or f a i l u r e of an o p e r a t i o n she planned to have d u r i n g the summer. Mrs. Smith r e a c t e d to the C l i n i c f i n d i n g s by ing  project-  the blame f o r B e t t y ' s problems on t o her husband.  critical  "She  was  of him and accused him, b e f o r e the worker, of not c o -  o p e r a t i n g i n her e f f o r t s t o h e l p B e t t y " . L i t t l e was  r e c o r d e d by the worker of the Davis' a t t i -  tude toward the C l i n i c f i n d i n g s .  They were d e s c r i b e d as b e i n g  "most a c c e p t i n g " and t h a t Judy's problem had been for  "clarified"  them. I t would appear q u i t e c o n c l u s i v e t h a t i n f o u r o f the  f i v e cases the parents were t h r e a t e n e d by the f i n d i n g s . r e a c t i o n was and t h e i r own  e i t h e r t o express d i r e c t concern about involvement  Their  treatment  i n i t , or t o deny t h e i r own  responsi-  67 bility  i n the problem by a p r o j e c t i o n of i t . I t may be t h a t withdrawal  i s i n d i c a t e d when parents  cannot accept the C l i n i c f i n d i n g s p o s i t i v e l y as a f u r t h e r step i n h e l p i n g them t o understand  the problem, i n c l u d i n g t h e i r  par-  ticipation i n I t . (7\  Parents' P r e p a r a t i o n of the C h i l d f o r the C l i n i c The w r i t e r noted t h a t the parents i n f o u r of the cases  s t u d i e d expressed d i f f i c u l t y w i t h or asked f o r h e l p i n i n t e r p r e t i n g the C l i n i c v i s i t s t o the c h i l d . Mrs. Anderson s a i d , "I don't  see how I can t e l l him  ( B i l l y ) t h a t the C l i n i c w i l l h e l p because I don't he i s unhappy". er's to  t h i n k he f e e l s  She was unable t o f o l l o w through w i t h the work-  suggestions and f i n a l l y e x p l a i n e d t o B i l l y t h a t he was going the C l i n i c  " t o meet a new  Mrs. Bennett  friend".  "wondered how L a r r y would f e e l when he  grew o l d e r and knew more about h i s c o n t a c t a t the C l i n i c .  She  was adamant i n h e r r e f u s a l to t e l l him the purpose of the v i s i t s " . Mrs. Cook was apprehensive the s c h o o l or neighbors for  about b r i n g i n g Jimmy  f i n d o u t . He was i n a d e q u a t e l y  the C l i n i c and was very f e a r f u l when he was brought  amination,  lest  prepared f o r ex-  " r e f u s i n g t o l e t the p s y c h i a t r i s t approach him". The worker r e c o r d e d i n the Davis f i l e :  "Mrs. Davis  v e r b a l i z e d concern about t e l l i n g Judy of the C l i n i c and f e l t was nothing t h a t Judy was concerned It  there  about a t the moment".  i s evident t h a t i n the f o u r cases the parents were  r e l u c t a n t t o e x p l a i n the C l i n i c t o the c h i l d i n terms o f h e l p w i t h t h e i r mutual problems a t home.  T h i s would seem to suggest  a non-acceptance of and l a c k of confidence i n the C l i n i c as f e l t by the parents themselves.  Perhaps they saw i t as an  68 admission t o the c h i l d o f t h e i r i n a b i l i t y t o d i s c i p l i n e him.  Re-  g a r d l e s s o f reasons, they f e l t unable t o a t t a c h any r e a l meaning t o the C l i n i c i n t h e i r i n t e r p r e t a t i o n o f i t t o the c h i l d . Guise, i n her study of parents who d i s c o n t i n u e d t r e a t ment, s t a t e s :  "Their e s s e n t i a l l y n e g a t i v e a t t i t u d e toward t h e  C l i n i c was apparent from t h e i r n e g l i g e n c e i n p r e p a r i n g t h e c h i l d 1 for Clinic  visits." I t would seem q u i t e reasonable t o p o s t u l a t e , t h e r e f o r e  f  t h a t parents may tend t o withdraw from treatment who have d i f f i c u l t y i n t e r p r e t i n g the C l i n i c t o t h e c h i l d on a r e a l i s t i c (8)  basis*  P a r e n t s ' Flow o f T a l k The w r i t e r w&s unable t o d e t e c t any common p a t t e r n i n  the f i v e cases around e i t h e r the p a r e n t s ' a f f e c t i n response t o the C l i n i c s i t u a t i o n , o r i n t h e i r tendency appointments.  t o keep o r break  I n f a c t , l i t t l e was mentioned i n the r e c o r d i n g s  about these areas; t h i s would seem t o be a r e g r e t t a b l e o m i s s i o n , A c o n s i d e r a t i o n of t h e p a r e n t s ' flow o f t a l k proved t o be more e n l i g h t e n i n g f o r the purposes  of t h i s study.  I n a l l the  cases the mothers t a l k e d f r e e l y d u r i n g the Interviews without p e r s o n a l a n x i e t y around t h e i r own r o l e s i n the c h i l d ' s Mmes. Anderson, Bennett and Cook spoke i n a f l u i d , n e g a t i v e , v o c a l l y - r e j e c t i n g manner.  problems.  intellectually-  Mmes. Davis and Smith  also  i n t e l l e c t u a l i z e d , but were more p o i s e d and s o c i a b l e , w i t h a charming,  defensive e x t e r i o r . I t may be t h a t parents who t a l k v o l u b l y and d e f e n s i v e -  l y , e p n s c i o u s l y aim t o d i s c u s s n o n - t h r e a t e n i n g and s u p e r f i c i a l things, —  tend t o r e v e a l more o f themselves 1 Guise, Jane, Op. C i t . , p . 173  than they can t o l -  69 e r a t e , then f e e l p r e s s e d to withdraw. have to be compared w i t h parents who  T h i s , however, would continue i n treatment  in  order t o a s c e r t a i n i f they, by c o n t r a s t , have d i f f i c u l t i e s ing —  d i f f i c u l t i e s which s i g n i f y a g r e a t e r investment  talk  of them-  s e l v e s i n a g r a d u a l l y formed, s u s t a i n i n g r e l a t i o n s h i p . The reader i s r e f e r r e d t o Appendix D of t h i s which i s a t a b u l a t i o n of r e s u l t s o b t a i n e d when the  study  withdrawal  i n d i c a t o r s i l l u s t r a t e d i n t h i s chapter i^ere a p p l i e d t o s i x a d d l t i o n a l cases.  These were s e l e c t e d a t random from the  f o r t y cases perused study.  original  at the outset as p o t e n t i a l m a t e r i a l f o r t h i  The r e s u l t s demonstrate t h a t a t l e a s t s i x ( t w o - t h i r d s )  o f the nine i n d i c a t o r s were present i n each of the s i x c a s e s . An i n t e r e s t i n g t r e n d which appears i n t h i s t a b u l a t i o n i s the grouping  of c e r t a i n i n d i c a t o r s i n t o what might be a syn-  drome or a c o l l e c t i o n of symptoms. "F",  "H",  and  " J " , i n d i c a t o r s 1, 3,  For example, i n cases  "E",  4 and 5 are p r e s e n t .  Also,  i n d i c a t o r s 4 and 5 appear i n a l l s i x c a s e s . i n d i c a t o r s would seem to suggest  This grouping  of  c e r t a i n dynamic f o r c e s a t work  an e x p r e s s i o n , perhaps, of m u l t i - c a u s a t i o n i n the problem o f d i s c ont i n u a t i on. While i t i s acknoitfledged t h a t these r e s u l t s are by no means c o n c l u s i v e they do, however, h e l p to s t r e n g t h e n the p r o g n o s t i c v a l u e of the i n d i c a t o r s .  F u r t h e r a p p l i c a t i o n of  them to a l a r g e number of d i s c o n t i n u e d cases w i l l h e l p to d e t e r mine t h e i r r e l i a b i l i t y as p r e d i c t i v e t o o l s .  In t h i s  connection  a subsequent r e s e a r c h d e s i g n might i n c l u d e an examination the t h i r t y withdrawal  cases which were not used i n t h i s  of  study.  70 I t would be important to determine whether or not the nine i n d i c a t o r s appear i n the same p r o p o r t i o n i n these t h i r t y as i n the f i v e examined i n t h i s study.  cases  In addition, a control  group should be a n a l y s e d i n order to determine the presence extent of withdrawal  and  i n d i c a t o r s among those cases which c o n t i n u e  through t o t e r m i n a t i o n .  The i n d i c a t o r s would be v a l i d a t e d i f  t h e i r i n c i d e n c e i n the withdrawal cases was  s i g n i f i c a n t l y greater  than i n the continued c a s e s . The Interviews T h i s p o r t i o n of the chapter w i l l c o n s t i t u t e an exami n a t i o n o f the m a t e r i a l i n the f i v e follow-up i n t e r v i e w s which seemed to emphasize the c l i e n t s ' d i s s a t i s f a c t i o n w i t h t h e i r C l i n i c experience.  T h i s w i l l be done i n the b e l i e f t h a t i t i s  v a l u a b l e f o r the s o c i a l work s t a f f a t the C l i n i c to be aware of methods or procedures which might  tend t o aggravate f e e l i n g s of  a n x i e t y or d i s i n t e r e s t i n the c l i e n t s , thus encouraging withdrawal from  their  treatment.  The q u e s t i o n a r i s e s as to what v a l u e can be p l a c e d on the v e r b a l responses of the c l i e n t . responses may  I t might be argued that these  conceal the r e a l reasons f o r withdrawal; t h a t  the  r e a l reasons are composed of a complex b l e n d i n g of c o n s c i o u s and unconscious f a c t o r s of which the c l i e n t h e r s e l f i s not aware.  fully  T h e r e f o r e , she cannot be expected e i t h e r to understand  or communicate her m o t i v a t i o n f o r withdrawal. T h i s study, w h i l e i n no way  n e g a t i n g the importance  unconscious m o t i v a t i o n s i n behaviour, would,also  suggest that  of an  understanding of the c l i e n t ' s p e r c e p t u a l p a t t e r n s ( I . e . c h a r a c t -  71 e r i s t i c ways of p e r c e i v i n g ) i s b a s i c t o treatment understanding  of the u n d e r l y i n g psychodynamics.  and t o an I n a sense  these  p e r c e p t i o n s "are d i s t o r t i o n s which grow out o f each i n d i v i d u a l ' s p a r t i c u l a r way  of p r e s e r v i n g h i s a t t i t u d e s and f e e l i n g , and h i s  r i g h t t o f e e l h u r t and d i s t r u s t f u l .  I t i s these d i s t o r t i o n s which  he r e v e a l s t o the counselor (worker) and which p r o v i d e the base  1 for  t h e i r work t o g e t h e r . "  The s o c i a l worker should be a b l e t o  r e c o g n i z e these p e r c e p t u a l p a t t e r n s and t o adapt h i s s k i l l s i n working w i t h them to enable the c l i e n t to move forward toward a more s a t i s f y i n g l i f e  experience.  Thus, the c l i e n t ' s v e r b a l r e -  sponses of d i s s a t i s f a c t i o n w i t h h i s C l i n i c c o n t a c t are r e p r e s e n t a t i v e of h i s p e r c e p t u a l p a t t e r n s and must be c o n s i d e r e d as v a l i d reasons  f o r withdrawal.  Reasons f o r Withdrawal (1)  The W a i t i n g P e r i o d : The most o u t s t a n d i n g c r i t i c i s m of the C l i n i c which ap-  pears i n f o u r o f the f i v e i n t e r v i e w s i s the w a i t i n g p e r i o d between the end of the d i a g n o s t i c p e r i o d and the b e g i n n i n g of continued services.  Mrs. Anderson spoke of i t as i f the  Clinic  had l e t her down: "They t o l d me  I'd hear from them i n December  but no one c a l l e d u n t i l J u l y " .  T h i r t e e n months was  l o n g and made me  l o s e i n t e r e s t " - (she may  " f a r too  have thought  t h a t the  C l i n i c lost interest i n her). The Bennetts d e s c r i b e d the t h i n g " - an i n s u l t to those who ask f o r h e l p i n the f i r s t iod  'wait' as a  "terrible  "had t o get up a l o t of nerve  place".  to  They blamed the w a i t i n g p e r -  f o r t h e i r f i n a l d e c i s i o n not t o c o n t i n u e .  " I f you'd get r i d  1 Gomberg, Robert & Lesson, Frances, Diagnosis and c e s s i n Family C o u n s e l i n g . F.S.A.A., 1951, p. 16.8  Pro-  72 of t h a t , you probably wouldn't l o s e so many p e o p l e " . Mrs. Cook s a i d the C l i n i c d i d n ' t h e l p Jimmy. t o l d me  there was  doing something  a problem behind h i s b e h a v i o u r .  they l e t us wait n e a r l y a y e a r .  "They  Instead of They s h o u l d  have spent l e s s time going i n t o my background and c o n c e n t r a t e d on Jimmy_ - e s p e c i a l l y when we're going t o have t o wait so l o n g . " Mrs. Davis d e s c r i b e d the w a i t i n g p e r i o d as " h i g h l y d e s i r a b l e " - a n e g a t i o n of the problem sought.  She  un-  f o r which C l i n i c h e l p  was  i m p l i e d t h a t , because of the t h i r t e e n month wait,  the C l i n i c people c o u l d n ' t have thought t h e i r problem  t o be a  s e r i o u s one.  She saw  process.  there been no w a i t i n g p e r i o d Judy would have a c -  Had  the wait as an i n t e r r u p t i o n of the whole  customed h e r s e l f to the c o n t i n u i n g C l i n i c v i s i t s as routine".  "something  A f t e r the wait however, " i t j u s t wasn't worth s t a r t =  i n g a l l over a g a i n . " Throughout, t h e r e seems to be a p a t t e r n e d f e e l i n g tone of r e j e c t i o n .  I n e f f e c t , the C l i n i c  (worker) o f f e r e d h e l p ,  expressed i n t e r e s t , t h e n devalued the problem saying, "we  are too busy to h e l p you now  from us when we have more time".  and c a s t i t a s i d e ,  - you can expect a c a l l  These are r a t h e r h a r s h words  but nonetheless r e a l i s t i c i n terms of the dynamics of some emot i o n a l l y d i s t u r b e d f a m i l i e s who  seek o u t s i d e h e l p .  C l i e n t s whose dynamic p a t t e r n s show s t r o n g unmet  de-  pendency needs w i l l probably have g r e a t d i f f i c u l t y t o l e r a t i n g a waiting period.  For example these p a t t e r n s e x i s t i n cases where  the p a r e n t s , p a r t i c u l a r l y the mother, show themselves  to have un-  r e s o l v e d dependent t i e s t o one of t h e i r p a r e n t s ; (e.g. Mrs.  Cook);  or i n cases i n which the parents are e x p e r i e n c i n g d i f f i c u l t y i n  73  the r e s o l u t i o n o f t h e i r dependency on each other; Smith)•  (e.g. Mrs.  A l s o , t h e r e a r e c l i e n t s who present a facade o f com-  petence and s e l f - s u f f i c i e n c y . pensatory  T h i s , i n r e a l i t y , may be a com-  mechanism by which e a r l y f r u s t r a t e d dependency needs  are d i s g u i s e d ; (e.g. Mrs. B e n n e t t ) .  The h o s t i l e component of  dependency s h o u l d not be overlooked;  t h i s i s f r e q u e n t l y used as  a r e t a l i a t o r y weapon by the c l i e n t . S o c i a l workers a t the C l i n i c would be w e l l a d v i s e d t o a l e r t themselves f o r those d e p r i v e d , dependent c l i e n t s t o whom the w a i t i n g p e r i o d w i l l mean r e j e c t i o n and who a r e l i k e l y t o r e t a l i a t e by d i s c o n t i n u a t i o n . i o d should seemingly  The i l l  e f f e c t s of the w a i t i n g p e r -  vary i n i n v e r s e p r o p o r t i o n t o t h e ego  s t r e n g t h s of the c l i e n t . The w a i t i n g p e r i o d w i l l be d i s c u s s e d f u r t h e r i n Chapt e r Four i n terms o f suggestions and recommendations f o r a l l e v i a t i n g some o f i t s d e s t r u c t i v e elements f o r the c l i e n t . (2)  Lack of Concrete S e r v i c e s : I t has been demonstrated i n the case s t u d i e s t h a t  c l i e n t s who withdraw from treatment approach t o t h e problem as a defense ment.  tend t o have an i n t e l l e c t u a l against personal involve-  I n other words, they may tend t o p l a c e the r e s p o n s i b i l i t y  f o r cure s o l e l y onto the C l i n i c .  This would cause them t o ex-  pect concrete s e r v i c e s (e.g. a d v i c e and d i r e c t i o n ) which, i f app l i e d , would m a g i c a l l y cause the problem t o d i s a p p e a r .  With t h i s  i n mind, the w r i t e r examined h i s i n t e r v i e w s w i t h the c l i e n t s t o determine whether or not such a p a t t e r n was e v i d e n t . Mrs. Anderson s t a t e d t h a t the C l i n i c f a i l e d t o g i v e her the f a c t u a l h e l p she needed i n coping w i t h B i l l y ' s problems.  74 She  r e l a t e d t h i s t o h e r i n t e r v i e w w i t h the p s y c h i a t r i s t - " I  never d i d f i n d out what he thought o r what he s a i d t o B i l l y " , R e f e r r i n g to the C l i n i c f i n d i n g s , she s a i d , "I r e a l l y  didn't  f i n d out anything." S i m i l a r l y , Mrs. Bennett c r i t i c i z e d the C l i n i c which had  i n no way g i v e n them the k i n d o f h e l p they wanted, "or needed".  The proposed "treatment" f o r L a r r y was r i d i c u l o u s ; i n e f f e c t , i t threatened Mrs.  h e r own need t o enforce r i g i d d i s c i p l i n a r y  Cook expressed  a l i k e a t t i t u d e , contending  measures.  t h a t she c o u l d  not understand why the C l i n i c d i d n ' t g i v e h e r h e l p w i t h Jimmy i n s t e a d o f c o n c e n t r a t i n g on h e r background. Mrs.  Davis  and Mrs.  To a m i l d e r degree,  Smith r e a c t e d s i m i l a r l y .  The former was  d i s a p p o i n t e d with the C l i n i c a t f i r s t and thought she was g e t i n g nowhere.  She f i n a l l y decided  i t was a s i t u a t i o n which p e r -  m i t t e d a " c a t h a r s i s f o r the mother", t h i s made h e r " f e e l " she was being helped.  Mrs. Smith f e l t  "cheated" because o f h e r short  c o n t a c t w i t h the p s y c h i a t r i s t .  T h i s meant t h a t he d i d n o t have  time t o g i v e h e r d i r e c t h e l p or c o u n s e l . I t would seem reasonable, concrete draw.  s e r v i c e s are wanted or a r e expected by c l i e n t s who w i t h -  T h i s e x p e c t a t i o n , as a l r e a d y i n d i c a t e d , tends t o be a  mechanism by which parents (3)  t h e r e f o r e , t o suggest t h a t  avoid  self-involvement.  Reassignment: Reassignment as a reason f o r d i s c o n t i n u a t i o n was not  e s t a b l i s h e d as a common p a t t e r n i n t h e f i v e i n t e r v i e w s it  d i d seem o p e r a t i v e t o some extent  i n the Davis  case.  although Mrs. Davis  75 came t o the C l i n i c f o r one Interview had  elapsed.  a f t e r the waiting p e r i o d  (This i n f o r m a t i o n was not r e c o r d e d  on the f i l e but  was v o l u n t a r i l y g i v e n t o the w r i t e r by Mrs. Davis.)  She i m p l i e d  that h e r d e c i s i o n t o withdraw became d e f i n i t e a t t h i s p o i n t . continue with a new worker would have seemed " j u s t l i k e all  over  To  starting  again". Both Mrs. Anderson and Mrs. Smith questioned  signment procedure but without  the r e - a s -  s u f f i c i e n t f e e l i n g t o i n d i c a t e that  i t was a f a c t o r i n t h e i r withdrawal. I t i s p o s s i b l e t h a t reassignment would be more damagi n g t o c l i e n t s when i t comes about d u r i n g a p e r i o d o f c o n t i n u a l 1 contact  r a t h e r than a f t e r a w a i t i n g p e r i o d o f c o n s i d e r a b l e  l e n g t h such as occurred  i n the case m a t e r i a l of t h i s study.  The  w r i t e r suggests t h a t a f u t u r e study might explore t h i s area o f reassignment. (4)  S u f f i c i e n t Help The  t h i s study.  Received  Smith case was s i n g u l a r among those According  interviewed f o r  t o Mrs. Smith, she d i s c o n t i n u e d  treat-  ment because o f the e f f e c t i v e n e s s of the h e l p r e c e i v e d a t the C l i n i c up t o the p o i n t of the w a i t i n g - p e r i o d .  'She was helped by  her caseworker both t o l o o k a t her problem and i n m o b i l i z i n g h e r strengths t o do something about i t . She h a p p i l y d e s c r i b e d the improved r e l a t i o n s h i p s between h e r s e l f , B e t t y , and her husband. She  a t t r i b u t e d these p o s i t i v e changes t o h e r C l i n i c  contact:  "Mother needed h e l p so t h a t c h i l d c o u l d be helped." I t would seem t h a t t h e r e a r e cases  i n which  sufficient  1 Miss F l e s c h ' s comments as d i s c u s s e d on page 2 would seem t o apply more s p e c i f i c a l l y t o c l i e n t s i n t h i s categorv  76 h e l p i s r e a l i z e d t o enable d i s c o n t i n u a t i o n w i t h p o s i t i v e  results  i n t h e form o f more harmonious r e l a t i o n s h i p s and a c o r r e s p o n d i n g decrease i n problem  symptomatology.  Although " s u f f i c i e n t h e l p  r e c e i v e d " i s a v a l i d r e a s o n f o r withdrawal from treatment, i t i s , i n a l l p r o b a b i l i t y , a m i n o r i t y one.  A study o f a l a r g e r  group  o f cases would perhaps have determined t h i s more e f f e c t i v e l y . (5)  L o c a t i o n o f the C l i n i c . There has been expressed concern among the C l i n i c  s o c i a l work s t a f f t h a t the l o c a t i o n o f the new C l i n i c  building  i n North Burnaby might be a d e t e r r a n t t o c l i e n t - c o n t i n u a t i o n . terms of p u b l i c t r a n s p o r t a t i o n f a c i l i t i e s ,  In  the C l i n i c i s not con-  v e n i e n t l y a c c e s s i b l e , p a r t i c u l a r l y to those i n the more h e a v i l y populated Vancouver C i t y a r e a . However, i t i s noteworthy  t h a t only Mrs. Anderson, o f  the f i v e f o l l o w - u p c o n t a c t s , s t a t e d d i s s a t i s f a c t i o n w i t h the North Burnaby l o c a t i o n .  She s t a t e d t h a t B i l l y would have to miss  a day of s c h o o l i n order t o keep an appointment  a t the C l i n i c .  The case summary and the i n t e r v i e w would suggest that t h i s was a minor r e a s o n f o r her withdrawal, s u b o r d i n a t e t o those pf the w a i t i n g p e r i o d and the l a c k o f concrete s e r v i c e s a v a i l a b l e t o h e r . Mrs. Smith, on the c o n t r a r y , o f f e r e d a d i f f e r e n t of view.  point  She d i d not r e f e r t o the g r e a t e r d i s t a n c e t o the new  C l i n i c as compared t o the o l d . vantages of a new b u i l d i n g , t o go t o a C l i n i c  Rather, she thought of the ad-  s u g g e s t i n g that i t would h e l p c l i e n t s  "that l o o k s l i k e a C l i n i c " .  I t does not seem p o s s i b l e , from t h i s study, t o p o s t u l a t e that the l o c a t i o n of t h e present C l i n i c i s a s i g n i f i c a n t r e a s o n f o r d i s c o n t i n u a t i o n , although i t was p o s s i b l y a c o n t r i -  77 b u t i n g f a c t o r i n the Anderson  case.  A l a r g e r group of d i s c o n -  t i n u e d cases might y i e l d a more d e f i n i t e answer. I n summary, the reasons f o r d i s c o n t i n u a t i o n based the f i v e follow-up i n t e r v i e w s  are f i v e i n number, the most i n -  s i s t e n t b e i n g the w a i t i n g - p e r i o d  and the l a c k of concrete s e r -  v i c e s ; to a l e s s e r degree reassignment, and the l o c a t i o n of the new  on  s u f f i c i e n t help received,  C l i n i c , were a l s o n o t e d .  Again, i t  i s suggested that these reasons f o r withdrawal be a p p l i e d i n a f u r t h e r study where, i n the l i g h t of a d d i t i o n a l i n t e r v i e w s , t h e i r r e l i a b i l i t y might be  strengthened.  CHAPTER IV Toward C o n t i n u a t i o n  The problem of d i s c o n t i n u a t i o n has been d i s c u s s e d both i n a g e n e r a l sense as i t r e l a t e s t o p r o f e s s i o n a l S o c i a l Work as a whole and s p e c i f i c a l l y as demonstrated  i n f i v e s e l e c t e d case  s t u d i e s and i n t e r v i e w s . A t o t a l of nine w i t h d r a w a l - I n d i c a t o r s emerged from the study of the cases which were suggested as having  some p r o g n o s t i c value i n determining which f u t u r e cases  be l i k e l y t o withdraw.  The c l i e n t s  1  might  reasons f o r withdrawal,  on the i n t e r v i e w s , were a l s o d i s c u s s e d .  F u r t h e r study was  based  sug-  g e s t e d to determine the r e l i a b i l i t y of both the i n d i c a t o r s of and reasons f o r withdrawal. The focus i n t h i s  chapter w i l l be on ways i n which the  C l i n i c s o c i a l work s t a f f might work through those s i t u a t i o n s which have been shown as d e t e r r e n t s to c o n t i n u a t i o n or completion of treatment• The Withdrawal One monstrate  Indicators of the main purposes of the study has been t o de-  these i n d i c a t o r s and to p o i n t out t h e i r  v a l u e as a base  i n p r e d i c t i n g which cases might d i s c o n t i n u e treatment.  Another  g o a l , however, i s that s o c i a l workers at the C l i n i c be a b l e t o r e c o g n i z e these i n d i c a t o r s i n e a r l y i n t e r v i e w s , and e v a l u a t e their  I n f l u e n c e on the t r e a t a b i l i t y  of the c l i e n t .  The worker  would then use h i s s k i l l s t o h e l p the c l i e n t n e u t r a l i z e the e f f e c t s of these i n d i c a t o r s which,  i f i g n o r e d , might  c r i p p l e the  treatment process and e v e n t u a l l y l e a d t o w i t h d r a w a l . These p a t t e r n s or i n d i c a t o r s may  w e l l be r e c o g n i z e d  79 as forms of r e s i s t a n c e which the c l i e n t u n c o n s c i o u s l y uses t o defend h e r s e l f a g a i n s t growth and change.  A d i s c u s s i o n of the  casework methods and s k i l l s a p p r o p r i a t e t o s u c c e s s f u l h a n d l i n g  . 1 o f these i n d i c a t o r s i s not w i t h i n the scope of t h i s s t u d y .  It  might be s a i d , however, t h a t i t i s important f o r t h e workers not only t o r e c o g n i z e the i n d i c a t o r s as r e s i s t a n c e , but a l s o t o d e a l w i t h them i n the casework s i t u a t i o n . s t a t e s : "The  Helen F l o r e s , i n her study,  f a c t ' t h a t the worker handles the r e s i s t a n c e . . . ap-  pears t o be s i g n i f i c a n t l y r e l a t e d t o the mother's c o n t i n u i n g i n  2 treatment." I t can be expected t h a t these r e s i s t a n c e or withdrawali n d i c a t o r s w i l l be more pronounced  i n some cases than o t h e r s , and  t h a t the i n c i d e n c e of d i s c o n t i n u a t i o n w i l l be i n d i r e c t t i o n to the s t r e n g t h of the i n d i c a t o r s .  propor-  I t cannot, t h e r e f o r e ,  be  s t r e s s e d too s t r o n g l y t h a t C l i n i c workers s h o u l d be on the a l e r t to d e t e c t these i n d i c a t o r s and to be aware o f t h e i r p r o g n o s t i c implications. Flores continues: " E a r l y r e c o g n i t i o n of r e s i s t a n c e and other s i g n s of i n s u f f i c i e n t motivation i s e s s e n t i a l i n helping parents t o make the most b e n e f i c i a l use of the c h i l d guidance treatment. The c l i e n t may be h e l p e d to r e cognize t h a t he i s not yet ready f o r the k i n d of treatment the c h i l d guidance c l i n i c has to o f f e r , and may then be r e f e r r e d t o another r e s o u r c e more geared t o the k i n d of h e l p he i s a b l e t o accept a t the time. F u r t h e r , e a r l y r e c o g n i t i o n of i n s u f f i c i e n t m o t i v a t i o n f o r treatment may a l l o w f o r worki n g through the b l o c k s t h a t prevent the parent from f u l l y m o b i l i z i n g h i m s e l f to continue treatment. Consequently, t h e r e w i l l be more e f f e c t i v e u t i l i z a t i o n of the s e r v i c e s of the agency which are i n such great demand and such s h o r t s u p p l y . " 3  1 See Kennedy, Ramona, I n i t i a l R e s i s t a n c e of Parents t o Casework S e r v i c e s i n a C h i l d Guidance S e t t i n g . U n i v e r s i t y o f B r i t i s h Columbia MSW T h e s i s , 1957.  2  F l o r e s , Helen,. R e s i s t a n c e as an I n d i c a t o r of M o t i v a t i o n f o r C h i l d Guidance. Smith C o l l e g e S c h o o l f o r .Social. Work, Master of S o c i a l S c i e n c e T h e s i s , 1954, p. 3 3 .  3  F l o r e s , Helen, I b i d , p.  37  80 The workers c a n perhaps be helped  t o an e a r l y  recog-  n i t i o n o f these i n d i c a t o r s by s t r i v i n g c o n s t a n t l y t o improve t h e i r s k i l l s i n r e l a t e d areas.  A g r e a t e r emphasis on f a m i l y  t e r n s or f a m i l y d i a g n o s i s i s p e r t i n e n t .  pat-  Here, the i n t e r a c t i o n  between s i g n i f i c a n t members o f a f a m i l y i s a v i t a l f o r c e a f f e c t i n g the prognosis  of any member ( s ) who i s seeking  a more h e a l t h y  degree o f p e r s o n a l or f a m i l y adjustment through the medium of casework treatment a t the C l i n i c . I n a r e l a t e d sense, a d i s c r i n i n a t i n g and a c c u r a t e tem  or r e c o r d i n g w i l l a s s i s t both i n b r i n g i n g these f a m i l y  syspat-  t e r n s i n t o a c l e a r e r f o c u s , and i l l u m i n a t i n g such withdrawal i n d i c a t o r s as may be present  i n the c a s e .  F i n a l l y , but by no means  c o n c l u s i v e l y , perhaps the f o r m u l a t i o n o f the p s y c h o s o c i a l n o s i s should  diag-  i n c l u d e an e v a l u a t i o n o f the c l i e n t ' s a b i l i t y to con-  t i n u e treatment.  This would b r i n g the problem o f withdrawal t o  the f o r e i n the e a r l y stages  o f the case and so h e l p t o impress  upon the worker the importance ,of b e i n g a l e r t t o i t s various manifestations. Reasons f o r D i s c o n t i n u a t i o n I t was demonstrated i n Chapter Three t h a t one reason f o r d i s c o n t i n u a t i o n which appeared i n the follow-up was " s u f f i c i e n t h e l p r e c e i v e d . " category  interviews  The cases t h a t come w i t h i n t h i s  would, t h e r e f o r e , seem t o be t r e a t a b l e under a b r i e f  s e r v i c e form o f c o n t a c t . be r e c o g n i z e d  I t i s suggested t h a t these cases might  as those i n which t h e r e i s p o s s i b l y not much depth  t o the c h i l d ' s symptomatic behaviour " i n t h a t i t seems t o be s u p e r f i c i a l l y r e a c t i v e to the parents  o r to the t o t a l f a m i l y  sit-  u a t i o n ; t h e emotional h e a l t h and s t r e n g t h both I n t h e parents and  81 i n the c h i l d a r e b a s i c a l l y  sound; and the parents  show c o n s i d e r -  a b l e p o t e n t i a l f o r g a i n i n g an understanding o f themselves and o f the child., and thereby improving t h e i r r e l a t i o n s h i p s w i t h 1  each  other and with the c h i l d . " Greater  s k i l l by t h e C l i n i c  s o c i a l work s t a f f i n t h e r e -  c o g n i t i o n of cases which a r e amenable t o a b r i e f s e r v i c e c o n t a c t w i l l have b e n e f i c i a l ive areas.  results  i n both t h e r a p e u t i c and a d m i n i s t r a t -  I n a t h e r a p e u t i c sense the c l i e n t s who can respond t o  a b r i e f contact w i l l not be i n v o l v e d i n an extended, time-consumi n g process  which might tend to d i s t o r t  s u p e r f i c i a l l y increase t h e i r i n t e n s i t y , to withdraw from t r e a t m e n t . q u i r e d t o experience ued  the o r i g i n a l problems, and encourage the c l i e n t s  A l s o , these c l i e n t s w i l l not be r e -  the w a i t i n g - p e r i o d between i n t a k e and c o n t i n -  s e r v i c e s which has been demonstrated, i n many cases,  t o be a  reason f o r d i s c o n t i n u a t i o n . A d m i n i s t r a t i v e l y , b r i e f contact represent  cases, when a p p l i c a b l e ,  an economy o f s t a f f time i n terms o f those cases which  go on t o continued  services.  There i s a l s o the p o i n t t h a t  brief  s e r v i c e cases r e l i e v e t h e i r workers from the concern and d i s c o u r agement o f t e n a s s o c i a t e d n w i t h cases which a r e o b l i g e d t o go through the w a i t i n g - p e r i o d b e f o r e  effective  treatment s e r v i c e s  can be o f f e r e d . A concurrent  study i n the a r e a o f b r i e f  p o s s i b l y a s s i s t the C l i n i c  s o c i a l workers i n t h e i r  services w i l l recognition 2  of cases which c a n best respond t o t h i s type o f c o n t a c t .  This  H a l l o w i t z and C u t t e r , Op. c i t . p . 439 2  F r e e r , N.W. A B r e l i m i n a r v Survey o f B r i e f S o c i a l Work S e r v i c e s i n a C h i l d Guidance C l i n i c . U n i v e r s i t y o f B r i t i s h Columbia MSW Thesis,. 1957 •  82 r e c o g n i t i o n may  a l s o be  instrumental  i n e l i m i n a t i n g the  of " s u f f i c i e n t help r e c e i v e d " as a r e a s o n f o r  category  client-discontin-  uation. Although the procedure of reassignment d i d not i n the i n t e r v i e w s  emerge  as a strong reason f o r d i s c o n t i n u a t i o n ,  the  c l i e n t s generally stated t h e i r d i s s a t i s f a c t i o n with i t . Davis was  particularly  withdraw was  opposed, s a y i n g  prompted by her  the w a i t i n g - p e r i o d  had  that her  Mrs.  f i n a l d e c i s i o n to  i n t e r v i e w w i t h a new  worker  after  elapsed.  I t i s recognized  that the a d m i n i s t r a t i v e  of the C l i n i c s o c i a l workers i n t o the  i n t a k e and  organization  continued  ser-  v i c e s e c t i o n s n e c e s s i t a t e s reassignment f o r those c l i e n t s who to r e c e i v e continued  casevrork  services.  A d i s c u s s i o n of the  are un-  d e s i r a b i l i t y of reassignment would, t h e r e f o r e , be u n r e a l i s t i c t h i s study. s i z e a way  in  On the other hand i t would seem important t o emphaof h a n d l i n g  p o s s i b l e , not be  reassigment so that i t w i l l , as f a r as  instrumental  i n encouraging the c l i e n t t o  with-  draw from treatment. A valuable  approach t o the problem of reassignment  might be f o r the worker to d i s c u s s carefully iod.  i t w i t h the c l i e n t - f u l l y  - through s e v e r a l i n t e r v i e w s  There seems to be  prior  to the  mentioned by the worker.  waiting-per-  some tendency among c l i e n t s to say  they understand a c e r t a i n C l i n i c procedure the f i r s t Similarly,  worker w i l l accept at face value  that  time i t i s  t h e r e i s the danger t h a t  t h i s statement of the  However, i t i s g e n e r a l l y r e c o g n i z e d  i n the b e h a v i o u r a l  Hence, a c l i e n t may  the  client. sciences  t h a t i n t e l l e c t u a l understanding f r e q u e n t l y precedes both emoti o n a l understanding and acceptance.  and  state  83 her i n t e l l e c t u a l i z e d acceptance of reassignment, whereas, emotionally, the  she may  be unable to t o l e r a t e  it.  With t h i s  recognition,  worker might perhaps take a l o n g e r p e r i o d of time i n which t o  interpret,  and e x p l a i n the reasons f o r , reassignment. The c l i e n t w i l l p o s s i b l y need to have her f e e l i n g s  b a l i z e d and accepted by the worker,  ver-  thereby d e c r e a s i n g the pos-  s i b i l i t y of her e q u a t i n g reassignment w i t h r e j e c t i o n .  I t might  a l s o be a d v i s a b l e f o r the c l i e n t t o be a s s i g n e d t o the c o n t i n u e d s e r v i c e worker p r i o r t o the w a i t i n g p e r i o d and to be i n t e r v i e w e d - once or s e v e r a l times - by her new  worker a t t h a t p o i n t .  would make the c o n t a c t a f t e r the wait more meaningful and  This less  t h r e a t e n i n g to h e r . Perhaps the g r e a t e s t danger worker may est  i s t h a t the  appear, through the c l i e n t ' s eyes, t o have l o s t  i n her.  interest  i n reassignment  inter-  S k i l l f u l h a n d l i n g of the procedure - w i t h o b s e r v a b l e  and concern f o r the c l i e n t shown by both the o l d worker  and the new support.  - w i l l assure the c l i e n t o f the C l i n i c ' s  I t w i l l a l s o encourage  continuing  and s t i m u l a t e her t o remain i n  treatment. The follow-up i n t e r v i e w s r e v e a l e d that c l i e n t s who continue may  expect c o n c r e t e s e r v i c e s from the C l i n i c .  This  disex-  p e c t a t i o n has been d i s c u s s e d i n terms of i t b e i n g a defense against  s e l f - i n v o l v e m e n t ; a tendency to p r o j e c t ' r e s p o n s i b i l i t y f o r  " c u r i n g " the problem onto the C l i n i c .  To o f f s e t  t h i s danger  the  C l i n i c s o c i a l workers must, from the beginning,, attempt t o i n v o l v e the c l i e n t s i n assuming blems.  responsibility  f o r t h e i r own p r o -  84 Perhaps t h i s e x p e c t a t i o n o f concrete s e r v i c e s might be approached both by r e c o g n i t i o n and v e r b a l i z a t i o n of i t by t h e worker t o the c l i e n t i n b e g i n n i n g i n t e r v i e w s . c l u d e the worker's acceptance i n c l u d e encouraging  This would i n -  of t h i s e x p e c t a t i o n .  I t might a l s o  the c l i e n t t o d i s c u s s why she t h i n k s h e r p r o -  blem c a n be s o l v e d by the C l i n i c through c o n c r e t e , p r e s c r i p t i v e measures. At the same time the worker might, w i t h t h i s type o f client,  see the need f o r an i n t e n s i v e , d e t a i l e d , and r e p e t i t i v e  e x p l a n a t i o n o f the C l i n i c ' s f u n c t i o n and s e r v i c e s . all,  I t i s , after  the c l i e n t ' s r i g h t t o know what she can or cannot  expect i n  the way of h e l p . The worker s h o u l d be always a l e r t t o m a n i f e s t a t i o n s o f the c l i e n t ' s d i s s a t i s f a c t i o n w i t h a p a r t i c u l a r procedure.  For  example, the c l i e n t may r e s e n t the worker's focus on h e r background h i s t o r y ,  (e.g. Mr. and Mrs. B e n n e t t ) .  to e x p l a i n many times why t h i s i s n e c e s s a r y . some c l i e n t s ,  The worker may need I n the same a r e a  (e.g. Mrs. D a v i s ) , may be apprehensive  of what seems  to be aimless t a l k i n g on h e r p a r t d u r i n g the i n t e r v i e w s , seemingly without  any d i r e c t i o n from the worker.  The worker should spot  t h i s d i s c o m f o r t , support the c l i e n t i n h e r f e e l i n g s , and emphas i z e the purpose o f the i n t e r v i e w - r e l a t i n g i t ,  i f necessary -  to the agency's f u n c t i o n and to the c l i e n t ' s problem. The worker's c h o i c e o f words w i t h the c l i e n t  undoubtedly  a f f e c t s her f e e l i n g s , e i t h e r p o s i t i v e l y or n e g a t i v e l y , toward h e r C l i n i c experience.. Both Mrs. Anderson and Mrs. Bennett, cases examined i n t h i s study, were alarmed by the word S o c i a l workers who f r e q u e n t l y r e s o r t t o j a r g o n among  o f the 'treatment'.  themselves,  85 may  perhaps be  i n c l i n e d t o use these mysterious words i n i n t e r -  views, p a r t i c u l a r l y somewaht d i f f i c u l t of the C l i n i c ) .  i n r e g a r d t o methods or procedures which are t o e x p l a i n i n o r d i n a r y terms, (e.g. s e r v i c e s  The use of j a r g o n may  c r e a t e a communication-barrier  w e l l alarm the c l i e n t  and  between h e r s e l f and the worker.  S o c i a l workers a t the C l i n i c would do w e l l t o examine t h e i r  use  of words and, by p e r s i s t e n t p r a c t i s e , endeavour t o communicate i n simple terms which c l i e n t s can both understand  and  The follow-up i n t e r v i e w s a l s o suggested  accept. that c l i e n t s  are  o f t e n d i s a p p o i n t e d a f t e r t h e i r c o n t a c t s w i t h other d i s c i p l i n e s i n the C l i n i c .  The worker can a l s o assume r e s p o n s i b i l i t y i n t h i s  area, p r e p a r i n g the c l i e n t f o r these e x p e r i e n c e s .  T h i s might be  done near the beginning of c o n t a c t when the C l i n i c a l procedures reviewed w i t h the c l i e n t . the worker may  T h e n , p r i o r to the C l i n i c a l  are  examination,  i n v o l v e the c l i e n t i n a d i s c u s s i o n of what h e l p  she  expects f o r h e r s e l f , and her c h i l d , from the other d i s c i p l i n e s . T h i s should enable the worker t o assess and d i s c u s s w i t h the any u n r e a l i s t i c e x p e c t a t i o n s .  I t i s always v a l u a b l e t h a t the  c l i e n t know i n advance what t o expect.  L a t e r , she may  and r e c o g n i z e t h a t her worker understood, cepted her  client  l o o k back  a n t i c i p a t e d , and  ac-  feelings. The above suggestions are made i n the hope that they  h e l p t o s t r e n g t h e n the c l i e n t ' s f e e l i n g t h a t the C l i n i c can  may  and  wants t o a s s i s t her i n c o p i n g more h e a l t h f u l l y w i t h her problems. With t h i s confidence the c l i e n t w i l l be a b l e t o i n v e s t h e r s e l f i n the casework r e l a t i o n s h i p , seeking a s o l u t i o n to her problems through her own  growth, r a t h e r than through c o n c r e t e , c o r r e c t i v e  p r e s c r i p t i o n s from the  Clinic.  86 I t has  been shown t h a t the c l i e n t s i n t h i s study  garded the w a i t i n g - p e r i o d as the most o u t s t a n d i n g discontinuation. wait  Again,  cause of t h e i r  as w i t h the problem of reassignment, the  i s an a d m i n i s t r a t i v e problem, the r e s u l t of too many c l i e n t s  seeking the s e r v i c e s of the C l i n i c til  re-  i n terms of s t a f f numbers.  such time as there i s a s u f f i c i e n t l y l a r g e s t a f f at the  Un-  Clinic  to meet the needs of an i n c r e a s i n g number of c l i e n t s , the w a i t i n g p e r i o d would seem i n e v i t a b l e . not be on the values on how  Therefore  the emphasis here w i l l  i n the d i s s o l u t i o n of the wait, but  i t might be used by the workers as a t h e r a p e u t i c I t was  ego-strengths  tool.  s t a t e d i n Chapter Three t h a t c l i e n t s w i t h good  w i l l not experience  as much d i f f i c u l t y a c c e p t i n g  w a i t i n g - p e r i o d as those whose egos are weak. these  rather  I t i s p o s s i b l e with  'stronger' c l i e n t s t h a t the wait might be i n t e r p r e t e d as a  p e r i o d i n which they  could t e s t f o r themselves t h e i r gains  ved d u r i n g the d i a g n o s t i c e v a l u a t i o n p e r i o d . be d i s c u s s e d w i t h the c l i e n t by the new ledge and  support  the c l i e n t ' s new  At the same time the new  T h i s p l a n would best  worker who  would acknow-  c o n s o l i d a t i n g these  strengths.  worker c o u l d arrange t h a t , d u r i n g  wait, he would keep i n r e g u l a r contact w i t h the c l i e n t by The  client  difficulties  i f necessary,  the tele-  should a l s o be encouraged to c a l l the worker i n  the event t h a t she f e e l s the need of h i s h e l p . t a c t s any  achie-  s t r e n g t h s , and h i g h l i g h t the  wait as a p e r i o d of both t e s t i n g and  phone.  the  or problem areas  During  these  could be d i s c u s s e d ,  a s i n g l e i n t e r v i e w might be arranged  to h e l p  conand,  the  c l i e n t with a p a r t i c u l a r obstacle. The  r e g u l a r i t y of these  c l i e n t c o u l d be f a c i l i t a t e d i f a were adopted at the C l i n i c .  telephone  contacts with  'brought-forward' f i l i n g  Under t h i s system the f i l e s  the system of  those  87 c l i e n t s t o whom telephone  c o n t a c t s were due c o u l d be d i s t r i b u t e d  t o t h e i r r e s p e c t i v e workers each morning. calls,  A f t e r completing  the workers c o u l d then "BF" the f i l e s t o a l a t e r  the  date.  T h i s approach c o u l d be t h e r a p e u t i c f o r the c l i e n t i n two ways: i t would i n c r e a s e her f e e l i n g s o f a b i l i t y and confidence t o assume an a c t i v e , p a r t i c i p a t i n g r o l e i n blems; a l s o , the r e g u l a r telephone  d e a l i n g w i t h h e r own  pro-  contacts would assure her o f the  C l i n i c ' s c o n t i n u i n g i n t e r e s t i n and concern f o r her problems duri n g the w a i t i n g - p e r i o d and u n t i l c o n t i n u i n g casework s e r v i c e s could be o f f e r e d . There w i l l a l s o be the c l i e n t with weak  ego-strengths  who, d u r i n g the d i a g n o s t i c e v a l u a t i o n p e r i o d , might have d i f f i c u l t y r e l a t i n g to the worker i n a one-to-one r e l a t i o n s h i p .  This  diffi-  c u l t y might be a m a n i f e s t a t i o n of v a r i o u s p e r s o n a l i t y d i s t u r b a n c e s , such as the f e a r of dependency, l a c k of s e l f - w o r t h , r e s i s t a n c e t o p e r s o n a l involvement i n the problem, e t c . To t h i s p a r t i c u l a r of c l i e n t the w a i t i n g - p e r i o d presents  an o p p o r t u n i t y  t h r e a t e n i n g contact w i t h the C l i n i c .  Another type of c l i e n t  ego  type  t o break h i s whose  i s weak may c l i n g t o the worker d u r i n g the d i a g n o s t i c p e r i o d ,  then i n t e r p r e t the wait as a r e j e c t i o n of h e r by the worker. These 'ego-weak' c l i e n t s might respond w e l l t o r e g u l a r group s e s s i o n s a t the C l i n i c d u r i n g the w a i t i n g - p e r i o d .  I n con-  t a c t with others who share  these  s i m i l a r or d i f f e r e n t problems  c l i e n t s might develop an acceptance of themselves with the accompanying d e s i r e t o change, thus p r o v i d i n g a b e t t e r f o u n d a t i o n f o r c o n t i n u i n g casework s e r v i c e s f o l l o w i n g the w a i t .  These group  s e s s i o n s c o u l d be handled by one worker who would encourage the c l i e n t s t o develop,  through group p r o c e s s , a b e t t e r  of themselves through i n t e r e s t i n and understanding  understanding of o t h e r s .  88 D i s c u s s i o n s would l i k e l y tend t o c o n s i s t o f a s h a r i n g of c h i l d ren's problems,  ways o f h a n d l i n g these problems,  and would hope-  f u l l y l a t e r focus on the c l i e n t s ' r o l e i n the problems - t h i s being pursued by the group members  themselves.  The worker would enable each c l i e n t , through the more d i l u t e group r e l a t i o n s h i p , t o g r a d u a l l y b u i l d ego-strengths t e s t i n g t h e i r gains on and l o o k i n g f o r support t o the group-as-awhole.  Prom t h e support of the group-as-a-whole the i n d i v i d u a l  c l i e n t would perhaps  be a b l e t o move forward, a f t e r the w a i t i n g -  p e r i o d , t o a more meaningful caseworker,  one-to-one r e l a t i o n s h i p w i t h the  w i t h new s t r e n g t h s t o i n v o l v e h e r s e l f i n working  through  her problems t o a more mature l e v e l of adjustment. These suggestions f o r a t h e r a p e u t i c use of the w a i t i n g p e r i o d are by no means e x h a u s t i v e .  They should be supplemented  by t h e C l i n i c s o c i a l workers a t t h e i r s e c t i o n a l , s t a f f and, i f poss i b l e , i n t e r d i s c i p l i n a r y meetings where methods of d e a l i n g w i t h the i n d i v i d u a l problems o f c l i e n t s - i n c l u d i n g the problem  of discon-  t i n u a t i o n - can best be s t u d i e d and planned.  Conclusion An attempt has been made, i n t h i s study, t o e x p l o r e the problem  of d i s c o n t i n u a t i o n both from the p e r s p e c t i v e s of the C l i n i c  and the c l i e n t s . workers,  The s u g g e s t i o n was made t h a t the C l i n i c  i f a l e r t t o the m a n i f e s t a t i o n s o f withdrawal  social  as d e s c r i b e d  i n Chapter Three, can e a r l y r e c o g n i z e those cases that may tend t o discontinue.  T h i s r e c o g n i t i o n should be f o l l o w e d by the imple-  mentation of a casework p l a n designed t o h e l p the c l i e n t s t o work through t h e i r r e s i s t a n c e s , thereby e n a b l i n g them to continue t r e a t ment .  89  The c l i e n t s ' conscious reasons f o r withdrawal have a l s o been d i s c u s s e d t o g e t h e r w i t h suggestions as to how workers might  overcome those reasons which are based on p r a c t i c e s  e f f e c t i n g n e g a t i v e a t t i t u d e s i n the c l i e n t s toward It  the C l i n i c  the C l i n i c .  i s important t h a t the C l i n i c s o c i a l work s t a f f make  a concerted e f f o r t to understand the problem and decrease the r a t e of d i s c o n t i n u a t i o n .  D i s c o n t i n u a t i o n must, i n n e a r l y a l l i n -  stances, r e f l e c t the c l i e n t s ' d i s s a t i s f a c t i o n s w i t h the C l i n i c services. for  S o c i a l workers w i l l not adequately meet t h e i r goals  the c l i e n t s , themselves, or the C l i n i c under such c i r c u m s t a n c e s . C l i e n t s who  come f o r h e l p are e n t i t l e d to the  maximum use of s e l f and s k i l l s  workers'  i n h i s endeavour t o i n v o l v e them i n  casework treatment of s u f f i c i e n t l e n g t h to ensure f o r them a happ i e r adjustment  and a decrease of a n x i e t y .  S o c i a l workers them-  s e l v e s need the support and c o n f i d e n c e of c l i e n t - c o n t i n u a t i o n to r e i n f o r c e t h e i r v a l i d areas of p r o f e s s i o n a l competence and f o r s t i m u l a t i o n to i n c r e a s e these a r e a s . lic  The C l i n i c , which i s a pub-  community agency, w i l l serve the community best when i t s s e r -  v i c e s are used to completion by those who  come f o r h e l p .  These  goals w i l l be more r e a d i l y a t t a i n a b l e as the r a t e of d i s c o n t i n u a t i o n decreases through g r e a t e r understanding, refinement of s k i l l s , and continued research*,  THE GOVERNMtNT OF TOE PROVINCE OF BRITISH COUJMWA  C O R N E R G R A N D VIEW HIGHWAY A N D W I L L I N G D O N A V E N U E  SOUTH BURNABY, B.C. CANADA  APPENDIX A  Dear Mrs. We a t the C h i l d Guidance C l i n i c are a l xvays concerned about  i n c r e a s i n g our a b i l i t y t o h e l p  those i n the community who need our s e r v i c e s .  It  has o c c u r r e d t o us t h a t a good way i n which t o approach t h i s would be t o t a l k t o someone who has had contact w i t h the C l i n i c i n the p a s t .  We a r e a s k i n g  f o r your h e l p i n t h i s p r o j e c t . One of our s o c i a l workers,  Mr. Warde L a i d -  man, w i l l be c a l l i n g you by telephone next week to see i f he might arrange an i n t e r v i e w w i t h you a t your venience.  T h i s would be of a c o n f i d e n t i a l n a t u r e .  hope you w i l l t h i n k t h i s a c t i v i t y worthwhile  conWe  i n the be-  l i e f t h a t , by g i v i n g us your t h o u g h t f u l c r i t i c i s m s o f the C l i n i c , you w i l l be h e l p i n g us t o h e l p others i n a more s a t i s f y i n g way. Yours t r u l y ,  Director.  91 APPENDIX B Schedule  a. b. c. d. e. f.  f o r Case Summaries  1.  I d e n t i f y i n g data:  c h i l d ' s age sex symptoms r e f e r r a l source who brought the c h i l d l e n g t h of w a i t i n g p e r i o d between d i a g n o s t i c p e r i o d and c o n t i n u e d casework s e r v i c e s .  2.  Parents responses  3.  Parents' r e l a t i o n s h i p w i t h the C l i n i c : a. p a r e n t s ' expressed f e e l i n g s about and responses t o : - diagnostic evaluation period - the worker b. s e r v i c e s expected c. p a r e n t s ' p r e p a r a t i o n of the c h i l d for C l i n i c v i s i t s . d. p a r e n t s ' a f f e c t , flow of t a l k , and behaviour r e g a r d i n g appointment keeping as observed and r e c o r d e d by the worker.  t o and c o n c e p t i o n of the c h i l d ' s problem.  92  APPENDIX C  Schedule t o be Used as a Guide f o r I n t e r v i e w i n g C l i e n t s Have D i s c o n t i n u e d Treatment.  who  1.  Were you s a t i s f i e d w i t h the C l i n i c s e r v i c e s to your p o i n t of withdrawal?  2.  Was the w a i t i n g p e r i o d a f a c t o r i n your d e c i s i o n t o w i t h draw?  3.  Was the change i n s o c i a l workers a f a c t o r i n your d e c i s i o n t o withdraw?  4.  Has the problem which brought you t o the C l i n i c changed? Is i t b e t t e r ? Same? Worse? To what do you a t t r i b u t e t h i s ? Has h e l p been r e c e i v e d elsewhere?  5.  Was your contact w i t h the C l i n i c h e l p f u l ? i f not, how not?  6.  Were you g i v e n what you t h i n k t o be a s a t i s f a c t o r y e x p l a n a t i o n of C l i n i c procedures and of the need f o r p a r e n t p a r t i c i p a t i o n as w e l l as c h i l d ?  7.  How  I f so, how?  do you t h i n k the C l i n i c might improve i t s s e r v i c e s ?  93  APPENDIX D Frequency of "Withdrawal I n d i c a t o r s " i n S i x Randomly S e l e c t e d Cases Not Used I n T h i s Study.  1 INDICATORS-  E  F  1  1  G  -  CASES H  1  1.  Kind of r e f e r r a l  2.  Who brought the c h i l d . (Lack o f f a t h e r p a r t i cipation)  _  —  Sex o f the c h i l d as r e l a t e d t o mother's host i l i t y t o her parent of the same sex  1  1  P a r e n t s ' "responses" t o t h e problem. (Mot h e r ' s concern f o r s e l f , not c h i l d )  1  1  1  1  5.  I n t e l l e c t u a l approach of p a r e n t s .  1  1  1  6.  Underestimation of problem  1  1  1  ?.  Negative r e a c t i o n of parents to C l i n i c findings.  mm  _  Parents' l a c k of p r e paration of c h i l d f o r Clinic.  1  Parents' flow of t a l k , f r e e but d e f e n s i v e  3.  k.  3.  TOTAL  I  z  J  TOTAL  1  i  I 1  1  1  _  3  1  k  1  1  6  1  1  1  6  1  1  -  5  1  1  1  3  1  ?  1  1  k  1  1  1  -  -  1  7  7  6  6  6  7  »  1  1.  As d e f i n e d and d e s c r i b e d i n Chapter  2.  Question marks i n d i c a t e a s u g g e s t i o n t h a t the " i n d i c a t o r " was present, a l t o u g h t h e r e was i n s u f f i c i e n t evidence t o warrant a c o n c l u s i v e r a t i n g  Three.  39  94 BIBLIOGRAPHY Books E n g l i s h , 0. Spurgeon, and Pearson, G e r a l d H. J„, Common Neuroses of C h i l d r e n and A d u l t s . W.W. Norton & Co. New York, 1937. P l e s c h , Regina, Treatment C o n s i d e r a t i o n s i n the Reassignment of C l i e n t s . Family S e r v i c e A s s o c i a t i o n of America, New York, 1947. Gomberg, M. Robert, & L e v i n s o n , Frances T., D i a g n o s i s and Process i n Family C o u n s e l i n g . New York; Family S e r v i c e A s s o c i a t i o n of America, 1951• Hamilton, Gordon, Theory and P r a c t i c e of S o c i a l Casework, Revised E d i t i o n , Columbia U n i v e r s i t y P r e s s , New York, 1951. Hamilton, Gordon, Psychotherapy i n C h i l d Guidance U n i v e r s i t y P r e s s , New York, 1947. Lowrey, Lawson G.,  P s y c h i a t r y f o r S o c i a l Workers.  E d i t i o n , Columbia U n i v e r s i t y P r e s s , New  f  Columbia Second  York,  1950.  S t a f f of the I n s t i t u t e f o r J u v e n i l e Research, C h i l d G u i d ance Procedures, Methods and Techniques Employed a t the I n s t i t u t e f o r J u v e n i l e Research, D. App l e t on-Century Company, Inc., New York, 1937. Stevanson, George S. and Smith, Geddes, C h i l d Guidance C l i n i c s , A Quarter Century of Development, New York, The Commonwealth Fund, 1934. T r u i t t , Ralph P . "Community C h i l d Guidance C l i n i c s " , The C h i l d Guidance C l i n i c and the Community New York, The Commonwealth Fund, D i v i s i o n of P u b l i c a t i o n s , r  1928.  Witmer, Helen L e l a n d , P s y c h i a t r i c C l i n i c s f o r Children,, York, The Commonwealth Fund, 1940".  New  Witmer, Helen L e l a n d , S o c i a l Work. An A n a l y s i s o f a S o c i a l I n s t i t u t i o n , F a r r a r E. R i n e h a r t , I n c . , New York,  19^2.  Articles Ackerman, Nathan W. & S o b e l , Raymond, "Family D i a g n o s i s : An Approach t o the Pre School C h i l d , " American J o u r n a l of O r t h o p s y c h i a t r y . V o l . XX, 1950.  95  BIBLIOGRAPHY Articles Coleman, J u l e s ; Short, Genevieve; and H i r s c h b e r g , J . C o t t e r ; "The Intake I n t e r v i e w as the Beginning of P s y c h i a t r i c Treatment i n C h i l d r e n ' s Cases," American J o u r n a l of P s y c h i a t r y . CV, 1949, PP. 183-86. H a l l o w i t z , David and C u t t e r , A l b e r t V., M.D., "Intake and the W a i t i n g L i s t : A D i f f e r e n t i a l Approach". J o u r n a l of S o c i a l Casework, December, 1954. Scherz, Frances H. "What i s Family-Centered Casework. V o l . XXXIV, 1953.  Casework", S o c i a l  S i p o r i n , Max. "A Family-Centered Casework i n a . . P s y c h i a t r i c S e t t i n g " , S o c i a l Casework, A p r i l , 1956. Witmer, Helen, and Students, "The Outcome of Treatment i n a C h i l d Guidance C l i n i c , A Comparison and an E v a l u a t i o n " , Smith C o l l e g e S t u d i e s i n S o c i a l Work. V o l . I l l , June,  1933.  Other S t u d i e s F l o r e s , Helen, R e s i s t a n c e as an I n d i c a t o r of M o t i v a t i o n f o r C h i l d Guidance. Smith C o l l e g e School f o r S o c i a l Work Master of S o c i a l Science T h e s i s , 1954. Guise, Jane F l a g g , "Withdrawal and C o n t i n u a t i o n i n a C h i l d Guidance C l i n i c . Smith C o l l e g e School f o r S o c i a l Work Master of S o c i a l S c i e n c e T h e s i s , 1952. M o s l i n , Ralph Sidney, D i f f e r e n t i a l Treatment In C h i l d ance Casework U n i v e r s i t y of B r i t i s h Columbia Thesis, 1952. r  GuidMSW  

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