UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Differential treatment in child guidance case work : an analysis of case work treatment methods in work… Moslin, Ralph Sidney 1952

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1952_A5 M6 D5.pdf [ 4.76MB ]
Metadata
JSON: 831-1.0106799.json
JSON-LD: 831-1.0106799-ld.json
RDF/XML (Pretty): 831-1.0106799-rdf.xml
RDF/JSON: 831-1.0106799-rdf.json
Turtle: 831-1.0106799-turtle.txt
N-Triples: 831-1.0106799-rdf-ntriples.txt
Original Record: 831-1.0106799-source.json
Full Text
831-1.0106799-fulltext.txt
Citation
831-1.0106799.ris

Full Text

DIJ?FEREHTIAL TREAIMEEH? IN CHILD  GUIDANCE CASE WORK An Analysis of Case Work Treatment Methods i n Work with 40 Mothers of Pre-School Chil-dren with Behaviour Problems, Vancouver Child Guidance C l i n i c , 1950. by RALPH SIDNEY MOSLIH Thesis submitted i n pa r t i a l fulfilment of the requirements for the Degree of MASTSR 07 SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1952 The University of B r i t i s h Columbia ABSTRACT In th i s study, emphasis has been placed on the fact that case work treatment with mothers depends upon the mother's per-sonality. The analysis i s made from 4-0 case records of mothers of pre-school children who were, because of problems of one sort or another, treated at the Child Guidance C l i n i c at Van-couver i n 1950. The study analyzes case record's f o r the above group of mothers, and i t was noted that the mothers could be c l a s s i f i e d according to t h e i r personality type and a four-way c l a s s i f i c a t i o n i s derived. The c l a s s i f i c a t i o n of the four groups i s based upon the degree of adequacy of the mothers i n terms of such factors as feelings of worth, security, s e l f -confidence and several others. The mothers are described as "better than average", "average", "less than'average", and "incomplete information". ..The l a t t e r group represents those mothers who were seen only once, and therefore, i n s u f f i c i e n t material i s available to c l a s s i f y them according to the "adequacy rating" c r i t e r i a . Mothers who were "better than average" were found to benefit most from treatment. The "less than average" mothers benefitted le a s t . Treatment methods have been described d e s c r i p t i v e l y . This study has employed the c l a s s i f i c a t i o n of treatment methods as derived by Mr. Geoffrey Glover i n a previous study of a sim i l a r nature. Deviations from Mr. Glover's c l a s s i f i c a t i o n system are noted i n the text of the study.. S t a t i s t i c s are presented to show with what frequency the in d i v i d u a l methods are employed by the s o c i a l worker. The emphasis of the study i s upon the way the mother's personality influences the worker's choice of treatment methods. It i s noted that treatment i n general f a l l s into d i f f e r e n t , but over lapping phases. About 90 per cent of the treatment i s found to be of a supportive nature, and 10 per cent of a more intensive kind. Mothers received more interviews than children, 58 per cent and 31 per cent respect-i v e l y . Fathers received only 11 per cent of the interviews. A suggestion i s made that additional t r a i n i n g may be nec-essary i f workers are to work on more intensive l e v e l s and to meet t h e i r accepted r e s p o n s i b i l i t y i n tre a t i n g very severely disturbed and upset c l i e n t s . TABLE OF CONTENTS Chapter 1. E v o l u t i o n of the C h i l d Guidance Movement p. 1 D e s c r i p t i o n of C h i l d Guidance 1 Development of C h i l d P s y c h i a t r y 2 I n f l u e n c e of Fre u d i a n Psychology 7 C l i n i c a l Status of Parents 10 S o c i a l Workers In C h i l d Guidance 14 Chapter 2. Case Work Treatment Methods 17 D e f i n i t i o n of the Interview 17 Worker-Client R e l a t i o n s h i p 20 B a s i c Treatment Methods 23 D i f f i c u l t y i n C l a s s i f y i n g Methods 35 Chapter 3. Interviews w i t h Mothers 37 The C l i n i c a l Approach 37 Kinds of C h i l d r e n Treated at the C l i n i c 37 Cases D i s c o n t i n u e d A f t e r Conference 43 Short-term Treatment 45 " A t t i t u d e Therapy" 46 I n t e l l i g e n c e of C h i l d 48 Mother 1s P e r s o n a l i t y ' 49 Success of Case Work Treatment 51 Supportive Case Work Treatment 52 Areas of Treatment 59 Chapter 4 . D i f f e r e n t i a l Case Work Treatment 65 • Purpose of Treatment 65 D i a g n o s i s of P e r s o n a l i t y o f Mother 65 Importance of Supportive Treatment 66 I n t e r p r e t a t i o n as Treatment 68 I n s i g h t 68 Recommendation 69 Schedule B i b l i o g r a p h y TABLES Table 1 - Interviews Held With C h i l d , Mother and Father (Sample Group) Table. 2 - Frequency of.Interviews i n Each Case Shown by Problem or Reason f o r R e f e r r a l Table 3 - Cases Showing Number of Interviews Held A f t e r Diagnostic Conference by Problem or Reason f o r R e f e r r a l Table 4 - Cases Showing Number of Interviews Held Before Diagnostic Conference by Problem or Reason f o r R e f e r r a l Table 5 - Cases Showing Number of Interviews w i t h Mothers of C h i l d by I n t e l l i -gence Quotient Table 6 - Cases Showing Number of Interviews w i t h the C h i l d by I n t e l l i g e n c e Quotient Table 7 - Interviews w i t h Mother Held at C l i n i c , Home and by Telephone Table 8 - C l a s s i f i c a t i o n of Mother by M a t u r i t y Rating i n R e l a t i o n to Number of Interviews Received Table 9 - Status of Case at C l o s i n g Shown by Adequacy Rating of Mother Table 10 - Frequency of Case Y/ork I n t e r v i e w i n g Methods, P e r s o n a l i t y of Mother, Number of Interviews Table 11 - Stages of D i f f e r e n t i a l Case Work Treatment: In R e l a t i o n to Frequency of Case Work Techniques, M a t u r i t y of Mothers, and Number of Interviews Chapter 1 Evolution of the Child Guidance Movement Child guidance i s not, as some would have i t , merely sub-sidized p sychiatric service i n which c e r t a i n tasks are dele-gated to persons who have less t r a i n i n g than p s y c h i a t r i s t s . Rather, i t i s a new form of s o c i a l service, i n which psychi-a t r i s t s and s o c i a l workers co-operate i n helping parents and children resolve the d i f f i c u l t i e s they encounter i n l i v i n g to-gether. As Dr. Frederick A l l e n puts i t : The c l i n i c in:.dealingwith the problem of a c h i l d i s p r e c i p i t a t e d into situations involving not one but many people. We have to deal with the c h i l d and h i s immediate adults, the c h i l d and his s i b l i n g s , the c h i l d and hi s school and neighbourhood. Because he is a c h i l d , adults play an important part i n a l l these sit u a t i o n s . Out of vthe cross-currents set up by the s t r i v i n g s and misunderstandings, the hopes and fears, the loves and antagonisms of these v a r i -ous people emerges a problem i n the c h i l d ; and the c l i n i c i s asked to enter t h i s arena to harmonize the d i f f i c u l t i e s that may ex i s t . An adequate description of c h i l d guidance would lead f a r a f i e l d , f o r i t Is an end-product of ideas that have a long h i s -tory. Without tracing t h i s lineage, however, i t must be noted that present c h i l d guidance practice i s not based on a single, well-integrated body of theory, and that some of i t s divergences r e f l e c t only p a r t i a l l y articulated^ differences i n basic assump-tions about human conduct. The f i r s t : c h i l d guidance c l i n i c s were an outgrowth of the "new psychology" of "the Boston group"—William James, G. Stan-ley H a l l , Adolf Meyer, and t h e i r students, H.H. Goddard, William Healy, and others with similar i n t e r e s t s . These men represented a union of psychology-and psychiatry, both of which d i s c i p l i n e s , T". Frederick H. A l l e n , "Creation and Handling of Resistance In C l i n i c a l Practice," American Journal of Orthopsychiatry, 2:268, July 1932. t ' -2-under t h e i r influence, became humanistic. To James, "mind" was an active, moving power, and a l l i t s manifestations were of im-portance. I n d i v i d u a l i t y , i n i t i a t i v e , freedom were to him the main desiderata: with them assured, l i f e and growth were cer-t a i n . H a l l was an ardent geneticist and much given to exalting " i n s t i n c t - f e e l i n g s " over r a t i o n a l i t y . Meyer, who came into contact with these two men, had long been interested i n devel-opmental processes, especially as pertaining to the psychoses. He was an arch opponent of t h e o r e t i c a l systems and of abstrac-tions of any sort. As he says about h i s early work, to him "the facts of each case were more important than the assumptions of as yet problematic disease-processes".^" This search f o r f a c t s — a b o u t heredity, environment, education, performance, intere s t s , ambitions, physical and mental capacities--was the keystone of Meyer's psychiatric method, and his therapeutic p r i n c i p l e s were s i m i l a r l y d i r e c t and i n l i n e with common sense. To a l l these men, body and mind were a unity, behaviour being the expression of the adaptation and adjustment of the i n d i v i -dual as aswhole. The development of c h i l d psychiatry, and e s p e c i a l l y of child guidance, was dependent upon the emergence of a set of hypo-theses about human behaviour and i t s disorders that was neither physiological nor f a t a l i s t i c . In the United States such a conception came into being at the turn of the present century, when, as has been said, a group of psychologistsrand psychia-t r i s t s found that t h e i r views had much i n common. Their chief tenets were the following: a human being i s a l i v i n g whole, not a sum of elements or a mysteriously s p l i t organism composed T~. Adolf Meyer, "Thirty-Five Years of Psychiatry i n the United States and Our Present Out-look", American Journal of Psychi-atry, 8:9, July 1928. ~ ~ * of mind and "body. Mind, as Meyer put i t , i s a " s u f f i c i e n t l y organized l i v i n g being i n action, not a p e c u l i a r form of mind s t u f f " . 1 Behaviour, i n both i t s physiological and psychologi-c a l aspects, represents the individual's attempts at adjust-ment. This adjustment i s a progressive process, i n the course of. which personality and habits of l i v i n g develop. In that process, i n s t i n c t s and emotions, as w e l l \ a s : i n t e l l e c t u a l factors, play a r o l e , and environmental conditions are very important. From t h i s conception of human conduct, a theory about men-t a l disorders and t h e i r origins l o g i c a l l y followed. These d i s -orders were now regarded as being, f o r the most part, malad-justments of personality and behaviour rather than diseases of the nervous system. As Meyer put i t , "The concrete conduct and behaviour i s the main thing deranged i n our patients.... The mental facts we speak of are not mere thoughts but actual at-titu d e s , a f f e c t s , v o l i t i o n s , and a c t i v i t i e s , and possibly d i s -orders of discriminations". P r e c i s e l y how conduct could become deranged (the mechanics or dynamics of the process) was never c l e a r l y explained by Meyer, but he put great emphasis upon taking into consideration a l l possible f a c t o r s — o r i g i n a l endow-ment, special personality t r a i t s , home influences, habits, stresses of the environmental s i t u a t i o n , and bodily ailments. This use of the developmental survey, t h i s search f o r the time and circumstances under which the "mental tangles" f i r s t occur-red l e d Meyer to an interest i n childhood and i n early preven-t i o n . On t h i s subject he and G. Stanley H a l l , with his c h i l d p study s o c i e t i e s , had much i n common. Tl Adolf Meyer, "The Role of Mental Faxtors i n Psychiatry", American Journal of Insanity, 65:4-3, July 1908. 2. Helen Leland Witmer, Psychiatric Interviews with Children New York, The Commonwealth Fund, 1946, p. 6. ~ ~J" -4-While Meyer was improving h i s theories and methods and spreading among several state h o s p i t a l systems h i s belief, that most mental patients were persons who had f a i l e d to meet the test s of l i f e , other men were also gaining recognition f o r their own variants .of the psychological theory of. mental disorders. Boris S i d i s , Morton Prince, William James were promoting the-ories of the unconscious and of early childhood conditioning and were developing methods of tr e a t i n g minor psychoses. Wil-liam A. White and Smith Ely J e l l i f f e were propounding Freud's theories to America and integrating them into mental ho s p i t a l p r a c t i c e . A l l of t h i s made f o r a growing interest i n the i n -d i v i d u a l patient and led to the formal organization of the men-t a l hygiene movement i n 1909. With respect to children, how-ever, i t was Meyer:'s viewpoint that predominated, and i t was his theories that underlay the practices of the f i r s t c h i l d guidance clinics."*" The p e c u l i a r i t y of c h i l d guidance c l i n i c s ( f i r s t estab-l i s h e d under that name i n 1922 as demonstration units by the National Committee f o r Mental Hygiene and the Commonwealth Fund) i s that they o f f e r psychiatric treatment to children and s o c i a l case work service to parents simultaneously. They also include a psychologist on the " c l i n i c team", who examines and treats the children i f necessary, and they o r i g i n a l l y made provision f o r physical examination of patients as we l l . This " f o u r - f o l d approach" was a l o g i c a l derivative of the theory that based treatment on a detailed study of the patient's development, his environmental circumstances, physical and mental capacities, fe e l i n g s and desires. That theory has changed with the years, T~. Witmer, op. c i t . , p. 6. - 5 -but c h i l d guidance workers s t i l l maintain that, to be e f f e c t i v e , psychiatric treatment of children must usually be accompanied by case work services to parents. Even though the theory has been modified, the teamwork method has been retained, and par-ents have continued to be regarded as very important t i n the . c h i l d guidance process. Under any conception of psychiatry, parents are involved i n the treatment of children, f o r they i n i t i a t e the action and they carry out many of the therapeutic measures. When, however, parents are regarded as being, i n one way or another, respon-s i b l e f o r the children's d i f f i c u l t i e s or are thought to consti-tute the chief element i n the adverse environmental s i t u a t i o n , some d e f i n i t e p o l i c y regarding them must be devised i f psycho-l o g i c a l treatment i s to be successful. The f i r s t solution to the question of what to do about parents was based on Meyer's theory. According to Meyer and those who most closely follow him, "psychotherapy" i s the "regulation of action". "That i s why," wrote Meyer i n 1908, "we teach patients actually to take d i f f e r e n t attitudes to things. Habit-training i s the backbone of psychotherapy; sug-gestion merely a step to the end and of use-only to the one who knows-that the end can and must be attained. Action with f l e s h and blood i s the only safe c r i t e r i o n of e f f i c i e n t mental a c t i -v i t y ; and action and attitude and t h e i r adaptation i s the issue i n psychotherapy"^" It cannot be expected, however, that the weak ind i v i d u a l (Meyer's conception of the usual patient) can wholly learn to adjust to his si t u a t i o n . Hence Meyer adds that p s y c h i a t r i s t s must be concerned with "the adjustment of the T~, Adolf Meyer, op. c i t . , p. 48. -6-tasks of adaptation, a.straightening out of the s i t u a t i o n out-side the patient, the family and other problems of adjustment that may be too much for the patient". Carried over into c h i l d psychiatry, t h i s therapeutic pro-cedure consists of studying a l l the pertinent aspecrts of the c h i l d and his s i t u a t i o n , formulating a plan f o r the r e l i e f or resolution of the d i f f i c u l t i e s , and putting the plan into ac-t i o n . To t h i s end, the co-operation of both parents and c h i l d -ren has to be secured. Kanner, a representative of t h i s school of thought, accordingly advises p s y c h i a t r i s t s to create i n the c h i l d "confidence i n ourselves as well as self-confidence i n his a b i l i t y to overcome the d i f f i c u l t y " and to l e t the c h i l d know that the p s y c h i a t r i s t s think"well enough of him to " l e t him i n on the program that i s worked out together with him as well as f o r him, and that we expect him to take an active part i n i t s materialization". With parents, too, co-operation i s deemed the e s s e n t i a l of therapy. Accordingly, "the ex i s t i n g problem must be formulated to the parents frankly but t a c t -f u l l y , i n simple and understandable everyday language, devoid of professional terminologies, i n an inoffensive manner which would assume acceptance....Treatment should be planned with the parents and not dictated to them. They are e n t i t l e d to know why c:ertain recommendations are made. Advice must be concrete and palpable.... Every step must be made to appear l o g i c a l , reasonable, and h e l p f u l " . ^ Parents, i n t h i s conception of the scheme of things, are primarily the receivers of s c i e n t i f i c advice, on the basis of which i t Is hoped they w i l l "do something d i r e c t l y f o r t h e i r TT Adolf Meyer, op. c i t . , p.- 48. 2. Leo Kanner, Child Psychiatry, ( S p r i n g f i e l d , 111., C . C . Thomas, 1935), p. 1 2 4 . 3. Ibid., o. 127. -7-o f f s p r i n g and more i n d i r e c t l y work on themselves i n hi s be-h a l f " . 1 This approach to parents, while used i n some c h i l d guidance c l i n i c s , i s more c h a r a c t e r i s t i c of private psychiatric p r a c t i c e , where the parent presumably i s seeking a s p e c i a l i s t ' s advice andil i s expected to act upon i t . When t h i s conception of the therapeutic endeavour i s carried over into c h i l d guidance, the s o c i a l worker i s primarily a c o l l e c t o r of information f o r the p s y c h i a t r i s t and a purveyor of his recommendations to par-p ents, whom he helps to carry out the plans. Ch i l d guidance s o c i a l workers soon found that t h i s way of working with parents was often unsatisfactory. Perhaps i t was:: because, as s o c i a l workers, they did not convey to parents that sense of professional prestige and authority on which doctors so much r e l y . Perhaps, out of t h e i r longer association with parents, they saw more c l e a r l y what happened when parents were t o l d what they should do about t h e i r children's behaviour d i f -f i c u l t i e s . Perhaps i t was that they and the p s y c h i a t r i s t s with whom they worked came to have a broader conception of what they wanted to accomplish: not only a removal of. the symptoms that were d i s t r e s s i n g the parents but a reorganization of the emo-t i o n a l aspects of family l i f e , whereby the c h i l d would be given a fresh start toward normal development. Probably a l l these factors were involved, as well..as a change i n the th e o r e t i c a l substructure of the psychiatry on which they operated. The change i n theory was a very important factor. About the time the Commonwealth Fund demonstration c l i n i c s were es-tablished (1922), the dynamic psychology of Freud was receiv-ing much attention from p s y c h i a t r i s t s . Freud's theories had T~. Leo Kanner, op", c i t . , p. 126. 2. Jacob H. Conn, "Treatment of Fearful Children", American Journal of Orthopsychiatry, 11:744, October 1941. ' ±^2£i--8-been introduced into the United States considerably e a r l i e r , but i t took wartime experience with neurotic patients to convince many p s y c h i a t r i s t s of t h e i r importance. Freud's research con-firmed the basic postulates on which c h i l d psychiatry was based and added others that made the vagaries of human behaviour more understandable. Instincts (drives, impulses toward action) were regarded as the prime motive power, and many psychological processes were found to be unconscious. Behaviour was thought to have an emotional component not only i n i t s overtones but., fundamentally. There was an inner connection between a l l the experiences of an individual's l i f e : a " f a c t u a l , causal con-nection between e a r l i e s t experiences and a l l others" and "an inner unity i n the diverse s t r i v i n g s " . 1 Most Important f o r the development of psychotherapy, i t turned attention away from "What are the influences operating on the c h i l d ? " and fastened i t on "How i s the c h i l d u t i l i z i n g these experiences?" Applied to work with parents, these theories made i t ap-pear u n l i k e l y that parents would take an objective, i n t e l l e c t u a l attitude toward t h e i r c h i l d r e n 1 s problems or that they would be able to change t h e i r behaviour toward them i n accordance with- a. p r e s c r i p t i o n . The l i v e s of parents and children were seen to be emotionally intertwined. The feelings and attitudes of par-ents, which were regarded as the chief determinants of c h i l d -ren' s d i f f i c u l t i e s , were i n turn dependent upon the parents' own early emotional experiences. It seemed to follow that work with parents should be directed toward resolving some of t h e i r own emotional c o n f l i c t s , for otherwise i t was thought they would continue to act toward t h e i r children i n t h e i r accustomed man-W. Paul Schilder, "Personality i n the Light of Psychoanalysis", Psychoanalytic Review,'""""22:41","' January 1935. 2. David Levy, "Freud and g k i l d psychiatry", American Journal of Orthopsychiatry, 10 : 8 b i - s e f z , October I9to. - 9-ner, no matter how c l e a r l y they were t o l d that they must a l t e r t h e i r behaviour. 1 Parents, accordingly, came to be regarded as'patients, and various methods were devised by s o c i a l workers^ f o r helping them. This development:reached i t s climax i n Dr. David Levy's "attitude therapy", a procedure by which s o c i a l workers, under::the guidance of p s y c h i a t r i s t s , t r i e d to help parents discover the emotional o r i g i n of t h e i r adverse fe e l i n g s 2 toward t h e i r children. This new p o l i c y with respect to parents was p a r t l y occas-ioned by the fact that, f o r a l l i t s interest i n dynamic psych-ology, c h i l d guidance work was s t i l l l a r g e l y environmental i n nature. Psychiatric: treatment was usually l i m i t e d to children at least nine or ten years old, and even older children seldom had many interviews with a p s y c h i a t r i s t . It was c h i e f l y to changes i n home, school, and recreation that p s y c h i a t r i s t s looked f o r a l l e v i a t i o n of t h e i r patients' problems, and much of t h e i r own work consisted of t r y i n g to discover what kinds of changes were c a l l e d f o r . In t a l k i n g with children and i n think-ing about how they could be helped, many psychiatrist's were guided by Freudian e t i o l o g i c a l p r i n c i p l e s , but most of them (perhaps influenced by Watson's behaviourism) expected improve-ment i n t h e i r patients to come, i n the f i r s t instance, not so much from inner psychological growth as from change i n external circumstances, p a r t i c u l a r l y i n the attitudes of the parents. This s h i f t i n the c l i n i c a l status of parents— ;from that of givers of information and receivers of advice about t h e i r c h i l d -T~. This point of view i s described by Marion Kenworthy as being the one widely held i n c h i l d guidance c l i n i c s in.the early 1930's. Proceedings of the F i r s t International Congress on  Mental Hygiene (New York, 1932), 2:4-68. 2. David Levy, "Attitude Therapy", American Journal of  Orthopsychiatry, 7:103-113, January 1937. -10-ren to that of p a t i e n t s — h a d important consequences f o r c h i l d guidance work. More and more was learned about family l i f e , and i t became increasingly believed that«most problem c h i l d -ren's d i f f i c u l t i e s were the result of ch r o n i c a l l y unhealthy parent-child relationships rather than of s p e c i f i c traumata whose circumstances were to be discovered. The conception of parents as wholly r a t i o n a l human beings who could take advice about the psychological as well as about the physical handling of t h e i r children was almost completely discarded, and it twas established that, with few exceptions, c h i l d r e n could not main-t a i n the gains they made through ps y c h i a t r i c treatment unless-, the parents' feelings about them changed. As a r e s u l t , the o r i g i n a l conviction that c h i l d guidance required jointtwork on the part of p s y c h i a t r i s t s and. s o c i a l workers was strengthen-ed, and s o c i a l work changed"from history-taking and "environ-mental manipulation" to treatment of one kind or another. By the end of the mid-nineteen-thirties, however, a change i i i c h i l d guidance psychiatry was i n process. The stimulating conceptions derived from psychoanalytic, work with young c h i l d -ren were beginning to influence p r a c t i c e . Play was found to be an adequate substitute f o r discussion as a means of revealing young children's d i f f i c u l t i e s and giving help i n overcoming them. Psychiatric interviews themselves became less i n t e l l e c t -u a l , as the implications of the dynamic-theory, f o r therapy as well as f o r etiology, .became, apparent. Less emphasis was put on symptoms, as expressed i n behaviour and personality t r a i t s , and more on feelings and desires. In short, psychiatric study and p r e s c r i p t i o n gave way to psy c h i a t r i c treatment. -11-Tne c h i l d analysts from whom much of t h i s i n s p i r a t i o n came had themselves found that work with children involved doing something about parents. Anna Freud pointed out that, i n con-t r a d i s t i n c t i o n to adult patients, children do not take the i n i -t i a t i v e i n seeking treatment .,(in f a c t , ev.en t h e i r consent i s often not asked);•frequently they are not bothered about t h e i r ailments; they often lack insight and have l i t t l e desire to be cured. 1 To deal with these divergences from the s a t i s f a c t o r y adult analytic s i t u a t i o n , she made several modifications i n an-a l y t i c a l procedure and several suggestions regarding parents. Treatment by analysis, she thought, should be l i m i t e d to c h i l d -ren whose parents themselves have been^analyzed, or who maintain toward analysis a c e r t a i n trust or respect. Even so, she re-commended that c h i l d analysts should maintain some contact with p t h e i r patients u n t i l adulthood. Her:most recent statement •• (about c h i l d analysis) i s as follows: The patient's family cannot be excluded from the analysis. Insight into the seriousness of the neurosis, the decision to begin and to continue treatment, persistence i n the face of resistance or. to passing aggravations of the i l l n e s s are be-yond the c h i l d and have to be supplied by the par-ents. In c h i l d analysis the parents;' good sense plays the part the healthy part of the patient's conscious personality plays during adult analysis to safeguard and maintainnthe continuance to treatment.3 .Other c h i l d analysts made other suggestions. Dorothy Bur-lingham, f o r instance, emphasized the need f o r maintaining the interest and sympathy of the parents throughout a c h i l d ' s t r e a t -ment and, as means to that end, recommended keeping the mother informed about the treatment measures, e n l i s t i n g her interest TT Anna Freud, Introduction to the Technic of Child Analysis, (New York, Nervous and Mental Disease Publishing Co., 1928),p.3. 2.. Ibid., p. 45-58. 3. Anna Freud, "indications f o r Child Analysis", The Psvcho-analytic Study of the Child (New York. 1945), Vol."1, p. 129. -12*-by having her report ton her c h i l d ' s actions, and u t i l i z i n g her natural f e e l i n g of g u i l t so that 1 she would turn to the analysts, f o r help i n undoing the, harm she had done to her child." 1" In spite of their. i n c r e a s i n g interest i n dynamic psych-ology, c h i l d guidance workers did not adopt a l l these suggest-ions i n regard to work with parents, f o r t h e i r own experience led them to doubt the f e a s i b i l i t y of some of them. The psy-c h i a t r i s t s saw no p o s s i b i l i t y of continuing contact with t h e i r patients u n t i l adulthood, nor did they think that desirable i n most cases. Neither they nor the ps y c h i a t r i c s o c i a l workers agreed with the i m p l i c i t assumption that treatment i t s e l f would restore children to mental health; that a l l that was required from parents was permissiqnnthat children be treated. Perhaps the disagreement Is to be .attributed to the r e l a t i v e briefness, of psychotherapy i n a c h i l d guidance c l i n i c ; perhaps to the presence of s o c i a l workers on the c h i l d guidance team. However that may be, c h i l d guidance workers t r i e d to apply the principles of dynamic psychology to case work with parents :and evolved various methods of helping them with t h e i r problems. The s h i f t to d i r e c t treatment of young children, however, led to changes i n work with parents.-: The wisdom of attempting to treat parents f o r t h e i r own psychological d i f f i c u l t i e s came to be questioned, and s o c i a l workers began to maintain that parents should be accepted"in the role i n which they present themselves to a c l i n i c : not as mere informants, nor yet as patients, but as individuals who are troubled about a e s o c i a l and personal rel a t i o n s h i p i n which they are involved. This change resulted i n part from the fact that p s y c h i a t r i s t s wanted T~, Dorothy T. Burlingham, "Child Analysis and the Mother", Psychoanalytic Quarterly, 4 : 7 5 - 7 6 ,.January 1 9 3 5 . -13-new s e r v i c e s f r o m s o c i a l w o r k e r s , i n p a r t f r o m changes i n s o c i a l w o r k t h e o r y i t s e l f . 1 A s p s y c h i a t r i s t s came t o depend more and more u p o n t h e i r r own o b s e r v a t i o n s o f c h i l d r e n f o r t h e i r d i a g n o s t i c i m p r e s s i o n s , t h e y h a d l e s s n e e d f o r h i s t o r i e s o f symptom d e v e l o p m e n t ( t h o u g h 2 t h e s e a r e o f t e n s t i l l c o n s i d e r e d i m p o r t a n t ) a n d more i n t e r e s t i n d e s c r i p t i o n s o f t h e p a r e n t s ) p r e s e n t and p a s t a t t i t u d e s t o w a r d t h e c h i l d r e n . By t h e s e f a c t s t h e y w o u l d know t o what s i t u a t i o n s t h e i r p a t i e n t s ' a c t i o n s were a n a d j u s t m e n t . I n a d -d i t i o n , p s y c h i a t r i s t s w a n t e d t o h a v e t h e c h i l d r e n ' s i n t e r e s t i n t r e a t m e n t s t i m u l a t e d and s u s t a i n e d b y t h e p a r e n t s , and t h e y a l s o wanted t h e p a r e n t s t o s u p p o r t t h e change and g r o w t h t h e c h i l d r e n were e x p e r i e n c i n g i n t h e c l i n i c . Thus t h e s h i f t t o d i r e c t t r e a t m e n t o f c h i l d r e n p u t new r e s p o n s i b i l i t i e s o n t h e s o c i a l w o r k e r s i n c h i l d g u i d a n c e c l i n i c s and r e q u i r e d a new e m p h a s i s i n t h e i r work w i t h p a r e n t s . I n f a c t o f t e n more w o r k i s done w i t h p a r e n t s , e s p e c i a l l y m o t h e r s , t h a n w i t h c h i l d r e n . A t t h e V a n c o u v e r C h i l d G u i d a n c e C l i n i c , i n 195Q, . f i % - e i g h t pen-c e n t o f t h e i n t e r v i e w s were w i t h t h e m o t h e r s s t u d i e d , compared' w i t h t h i r t y - o n e p e r c e n t w i t h c h i l d r e n and e l e v e n p e r c e n t w i t h f a t h e r s . S o c i a l w o r k e r s came t o t h e c o n c l u s i o n t h a t i n f o r m a t i o n about p a r e n t s ' p r e s e n t and p a s t a t t i t u d e s ; t o w a r d t h e i r c h i l d r e n and m a i n t e n a n c e o f p a r e n t s ' i n t e r e s t c a n b e e b e s t s e c u r e d when a t t e n t i o n i s c e n t e r e d d i r e c t l y on a p a r e n t and c o n c e r n about any p r o b l e m s she may h a v e . T h i s seems t o be a r e a l i s t i c a p p r o a c h ; T~, V i r g i n i a R o b i n s o n , A C h a n g i n g P s y c h o l o g y i n S o c i a l W o r k , C h a p e l H i l l , N . G . , U n i v e r s i t y o f N o r t h C a r o l i n a P r e s s , 1 9 3 0 . 2 . Emmy S y l v e s t e r , "Symposium: P s y c h o t h e r a p y o f C h i l d r e n " , A m e r i c a n J o u r n a l o f O r t h o p s y c h i a t r y , 1 5 : 3 0 . , J a n u a r y 1 9 4 5 . -•144 f o r , o b v i o u s l y , p a r e n t s s e l e c t a c h i l d g u i d a n c e c l i n i c as a s o u r c e o f h e l p b e c a u s e t h e y a r e t r o u b l e d about t h e i r c h i l d r e n ' s m a l a d j u s t m e n t and ( p o s s i b l y ) t h e i r r e l a t i o n t o i t . 1 M o s t . c h i l d g u i d a n c e s o c i a l w o r k e r s , a c c o r d i n g l y , now t a k e as t h e i r t a s k t h e f o s t e r i n g and e n h a n c i n g o f t h e s t r e n g t h t h a t a p a r e n t d i s p l a y s when she d e c i d e s t o do s o m e t h i n g about an u n -p l e a s a n t t s i t u a t i o n . They t r y t o p r e p a r e t h e c h i l d f o r p s y c h o -t h e r a p y b y d i s c u s s i n g w i t h t h e p a r e n t , i n t h e i n t a k e i n t e r v i e w , hov; she w i l l p r e s e n t t o t h e c h i l d t h e p l a n o f c o m i n g t o t h e c l i n i c . They seek t o m a i n t a i n t h e p a r e n t s ' i n t e r e s t i n t h e c h i l d ' s t r e a t m e n t b y a c c e p t i n g t h e a m b i v a l e n c e o f t h e p a r e n t s ' d e s i r e s , h e l p i n g them t o d e c i d e what t h e y most want t o do a b o u t t h e i r c h i l d ' s p r o b l e m s , and d i s c u s s i n g w i t h them what i s b e i n g d i s c o v e r e d about t h e c h i l d ' s d i f f i c u l t i e s b y t h e p s y c h i a t r i s t o r b y t h e p s y c h i a t r i c s o c i a l w o r k e r . By t h e s e and o t h e r meas-u r e s t h e y s t r i v e t o be o f h e l p t o t h e p a r e n t s , t o t h e end t h a t t h e y c a n s u p p o r t t h e c h i l d ' s p s y c h o l o g i c a l g r o w t h a s i t r e c e i v e s ; : r e l i e f o r f r e s h i m p e t u s f r o m p s y c h o t h e r a p y . S o c i a l w o r k o f t h i s n a t u r e o f t e n l e a d s i n t o a d i s c u s s i o n o f a p a r e n t ' s own e m o t i o n a l c o n f l i c t s , e s p e c i a l l y t h o s e h a v i n g t o do w i t h f a m i l y r e l a t i o n s and d u t i e s , and i t may r e s u l t i n improvement i n t h e p a r e n t s ' own m e n t a l h e a l t h * S u c h , h o w e v e r , i s n o t i t s m a i n o b j e c t i v e . I t s p r i m a r y a im i s t o h e l p t h e p a r e n t t o w o r k out a p r o b l e m i n s o c i a l r e l a t i o n s h i p s and t h u s t o p r o v i d e a n e n v i r -onment i n w h i c h t h e c h i l d c a n c o n t i n u e t h e change he i n i t i a t e s i n t r e a t m e n t i n t e r v i e w s . C h i l d g u i d a n c e i s t h u s a j o i n t e f f o r t o f p s y c h i a t r i s t s and TT A lmena D a w l e y , " I n t e r - R e l a t e d Movement o f P a r e n t and C h i l d i n T h e r a p y w i t h C h i l d r e n " , A m e r i c a n J o u r n a l o f O r t h o p s y c h i a t r y , 9 : 7 4 8 - 7 5 4 , O c t o b e r 1939. psychiatric s o c i a l workers (and, i n some cases, c l i n i c a l psy-chologists) i n which r e s p o n s i b i l i t y f o r the various aspects of treatment i s de l i b e r a t e l y apportioned. However, i n t h i s study, the main concern i s with the s o c i a l worker's part i n the under-taking and does not attempt to show the method by which psy-c h i a t r i s t s operate. Moreover, the examples of " c h i l d guidance" case work i s li m i t e d to interviews with mothers, omitting other aspects of work i n the Vancouver Child Guidance C l i n i c . Even t h i s side of psyc h i a t r i c . s o c i a l work, howev.er, takes on special character because of the c h i l d guidance setting and procedures; hence the interviews with mothers, described throughout t h i s study, are supplemented by notations about the s o c i a l case work with children. The study does not aim to t e l l anything l i k e the whole story of theory and method. Interviewing techniques as well as treatment w i l l be found to d i f f e r from case to case, depending upon both the patient's needs and the worker's person-a l i t y and t h e o r e t i c a l conceptions. Nevertheless, these are variables i n a defined universe, and the c h i l d guidance concep-t i o n underlies them a l l . The present study has been prepared as a:descriptive rather than as an a n a l y t i c a l document. Its preparation was approached i h a s c i e n t i f i c , s p i r i t , but i t s emphasis has been more upon the p r a c t i c a l aspects of case work treatment than upon the s c i e n t i -f i c implications of psychiatry and s o c i a l work. The case re-cords of 40 mothers of pre-school children, who were treated at the P r o v i n c i a l Child Guidance C l i n i c of Vancouver i n 1950, are analyzed to show that the application of case work treatment methods i s dependent upon the strengths and weaknesses of a -16-mother's p e r s o n a l i t y . Against the background of the development and s c i e n t i f i c b a s i s of c h i l d guidance and case work from the p s y c h i a t r i c p o i n t of view, the next step w i l l ' b e a d e s c r i p t i o n of i n t e r v i e w i n g techniques as employed i n case work p r a c t i c e today at the Vancouver C h i l d Guidance C l i n i c . -17-Chapter.2 Case Work Treatment •••Methods For over a quarter of a century s o c i a l 1 workers have con-tinued t h e i r quest f o r methods of helping people which would he most e f f e c t i v e i n helping the p a r t i c u l a r kinds of c l i e n t s they were ca l l e d upon to help. • As,psychiatric p r i n c i p l e s were i n -corporated i n case work concepts, a l l aspects of treatment be-came more e f f e c t i v e . One of the steps taken i n making treatment more useful was the application of diagnostic c r i t e r i a : i n each case—the c l i n i c a l approach. Another was an increased interest i n and study of process recording of interviews. The c h i l d giiidance movement has brought not only psychi-a t r i c theory into the practice of s o c i a l work, but a. psycho-analytic a l l y orientated type of psychiatry which threw immedi-ate l i g h t on the oldest concern of s o c i a l work, namely, family i n t e r - r e l a t i o n s h i p s and i n t e r a c t i o n s . 1 This new psychiatry with i t s concept of unconscious c o n f l i c t , the emotional forces within the personality, and the i r r a t i o n a l character of much behaviour revolutionized the therapeutic approach. Treatment f o r the f i r s t time, could be directed to the inner c o n f l i c t as well as to the outer circumstances. In the present concept of case work, the attempt i s to gain access to thought and f e e l i n g , with the understanding that the c l i e n t must always involve h e r s e l f i n any r e a l change. Psychiatric knowledge, i n t u i t i o n , r e l a t i o n -ship, experience, and s o c i a l services are a l l parts of the ad-aptation that case work has made from psychoanalytic psychiatry. Diagnosis i s t i e d -in with understanding of the development of the t o t a l personality, both within i t s e l f and as::a reaction to T~, Gordon Hamilton, Psychotherapy i m C h i l d Guidance, Columbia University Press, New York, 1947, p. 10. -18-those f a m i l i a l and c u l t u r a l influences.which are the s o c i a l worker's stock i h t r a d e . 1 Thus there i s a "balance i n c h i l d guidance work between s o c i a l and c l i n i c a l considerations. S o c i a l case work, as practiced at the Vancouver Child Guidance C l i n i c , i n 1950, aimed at a fusion of p s y c h i a t r i c and s o c i a l s k i l l s i n a c h a r a c t e r i s t i c "design" of d i r e c t treatment and l i f e experiences with varied adaptations and a f l e x i b l e com-bination of methods. Like mental hygience c l i n i c s ih .TiOthersparts of the contin-ent, the Child Guidance C l i n i c of Vancouver i s both a s o c i a l and a health agency. Its selection of c l i e n t s , i t s diagnostic thinking and treatment goals help to i d e n t i f y the c l i n i c as a health resource. At the same time, the c l i n i c achieves i d e n t i -f i c a t i o n with the s o c i a l agencies of the community through the generic t r a i n i n g of a l l p s y c h i a t r i c s o c i a l workers i n the clinic. It i s a: common occurrence f o r workers i n the Vancouver Child Guidance C l i n i c , as i t has been since the C l i n i c opened i n 1932, to make constant r e f e r r a l to the p s y c h i a t r i s t f o r con-s u l t a t i o n on treatment of c l i e n t s . Consultation takes up a very greattpart of the p s y c h i a t r i s t ' s time; his function could be defined around diagnosis and consultation alone. However, t h i s i s work of primary importance f o r which only the psychi-a t r i s t i s trained. It i s recognized here, that the s o c i a l worker can take over in d i v i d u a l treatment i n most cases as long as the knowledge and experience of the more specia l i z e d person i s available through consultation. In the year 1950, a study of 40 private cases showed that the burden of treatment was carr i e d almost e n t i r e l y by s o c i a l workers; the proportion of 1. Gordon Hamilton, op. c i t . , p. 13. -19-these cases c a r r i e d by p s y c h i a t r i s t s was n e g l i g i b l e . P r i v a t e cases are those r e f e r r e d t o the c l i n i c by parents, p r i v a t e p h y s i c i a n s , speech t h e r a p i s t s , schools and se on, being d i f f e r -e n t i a t e d from those cases r e f e r r e d by s o c i a l agencies or by medical and h e a l t h agencies. The Interview Int e r v i e w i n g i n v o l v e s a close and subtle r e l a t i o n s h i p be-tween human beings. I t i n v o l v e s communication between two people. Because a c l i e n t can t h i n k and t a l k as w e l l as f e e l and experience, what she can t e l l the s o c i a l worker of her s i t u -a t i o n becomes the c h i e f medium f o r e x p l o r a t i o n , d i s c u s s i o n , e x p l a n a t i o n and establishment of what the s o c i a l worker c a l l s "a p o s i t i v e r e l a t i o n s h i p " . Rapport must be e s t a b l i s h e d between the two; a r e l a t i o n s h i p that w i l l , on the one hand, enable the c l i e n t to r e v e a l the e s s e n t i a l f a c t s of the s i t u a t i o n ; and, on the other, w i l l enable the worker to be most e f f e c t i v e i n h e l p -ing her. The s p e c i f i c kinds of help a worker can g i v e , and consequently, the s p e c i f i c sort of i n f o r m a t i o n he w i l l seek, of course, depends to a considerable extent upon the f u n c t i o n s of the agency. The treatment s i t u a t i o n i s used to help the c l i e n t r e l e a s e f e e l i n g s , t o support her ego, and t o increase her self-awareness by b r i n g i n g to her a t t e n t i o n her a t t i t u d e s and p a t t e r n s of be-haviour both i n l i f e experience and i n the i n t e r v i e w i n g t r e a t -ment s i t u a t i o n (although u s u a l l y more of the former), the case worker tending to use the transference to r e d i r e c t the psycho-l i g i c a l energies i n t o r e a l i t y channels. As an i n t e r v i e w becomes l e s s a means of meeting s p e c i a l needs and more a way of h e l p i n g -20-the i n d i v i d u a l to make fundamental changes i n a t t i t u d e s , i t may-be c l a s s i f i e d as treatment i n t e r v i e w i n g . In t h i s sense i t t becomes v e r y much a s k i l l . I n t e r v i e w i n g s k i l l r e s t s on a fundamental p r o f e s s i o n a l a t t i t u d e c a l l e d "acceptance". T h i s means acceptance of the c l i e n t as she i s — i n whatever s i t u a t i o n , no matter how unpleas-antt or uncongenial t o the worker, x^ith whatever behaviour, a g g r e s s i v e n e s s , h o s t i l i t y , dependency or l a c k of frankness she may ma n i f e s t . The Case Work R e l a t i o n s h i p The i d e a t h a t the r e l a t i o n s h i p o f worker and c l i e n t i s im-por t a n t i n h e l p i n g people t o h e l p themselves, i s one of the o l d e s t i n case work. The r e l a t i o n s h i p must be d i s c i p l i n e d f o r e f f e c t i v e use. P r o f e s s i o n a l r e l a t i o n s h i p s are not j u s t f r i e n d l y a s s o c i a t i o n s . However, the worker must have a warmth of i n t e r -est i n people and a s i n c e r e d e s i r e t o be h e l p f u l , r e s p e c t f o r the c l i e n t ' s f e e l i n g and c a p a c i t y to make her own p l a n s , per-c e p t i v e o b s e r v a t i o n and a s e n s i t i v e u nderstanding, and s k i l l i n impa r t i n g to the c l i e n t u nderstanding concerning human behaviour and adjustment. C l i e n t s b r i n g i n t o the case work r e l a t i o n s h i p f e e l i n g s and a t t i t u d e s and behaviour.which they have experienced w i t h o t h e r s . The c l i e n t tends t o r e a c t t o the case work s i t u a t i o n i n ways d e r i v e d from a t t i t u d e s l e a r n e d - a t home and c o n d i t i o n e d a l s o by other l i f e s i t u a t i o n s . 1 The " p r o f e s s i o n a l s e l f " i s c o n t r o l l e d towards the end the worker i s s e r v i n g — n a m e l y , to understand and meet the p s y c h o l o g i c a l and s o c i a l needs of c l i e n t s . The r e l a t i o n s h i p h o l d s on a b a s i s of p o s i t i v e f e e l i n g — s o m e t i m e s Tl Annette G a r r e t t , I n t e r v i e w i n g , I t s P r i n c i p l e s and Methods, Family S e r v i c e A s s o c i a t i o n of America, New York, N.Y., 1942,p.19. - 2 1 -w i t h phases of negative or "mixed", that i s , ambivalent, f e e l -i n g s — a s long as the treatment continues. The r e l a t i o n s h i p ranges from an o b j e c t i v e one i n which the worker i s seen much as he i s — l i k e d or d i s l i k e d , t r u s t e d or d i s t r u s t e d on the b a s i s of h i s s k i l l , courtesy, e f f i c i e n c y and understanding, t o one i n which s u b j e c t i v e f e e l i n g s coluur the c l i e n t ' s p e r c e p t i o n of the worker who i s o f f e r i n g treatment. The extent to which the c l i e n t w i l l make use of the case work r e l a t i o n s h i p depends upon the kind and q u a l i t y of her emotional need and i t s place i n the harmony of her p e r s o n a l i t y . By no means do a l l case work r e l a t i o n s h i p s c a l l f o r equally strong w o r k e r - c l i e n t r e l a t i o n s h i p . While r e l a t i o n s h i p i s al\vsys i n v o l v e d i n case work, the more intimate the m a t e r i a l discussed and the more disturbed the c l i e n t , the more i s i t e s s e n t i a l that i t be strong enough to permit the c l i e n t d i s c l o s u r e of her f e e l i n g s and to support her i n these d i s c l o s u r e s . Conversely, the more s u p e r f i c i a l i s the d i s c u s s i o n , the l e s s need has the c l i e n t f o r a strong supportive r e l a t i o n s h i p . That i s , i n so f a r as the case worker i s able to create a comfortable atmos-phere i n which the c l i e n t f e e l s accepted and her need recog-n i z e d as her need, i n so f a r as her r i g h t to manage her own a f f a i r s i s respected and her energies not d i s s i p a t e d i n s e l f -j u s t i f i c a t i o n , a sense of f a i l u r e , or a s t r u g g l e of w i l l s , she w i l l experience a k i n d of r e l a t i o n s h i p . The mere experience of having a f r i e n d l y and i n t e r e s t e d worker l i s t e n i n g a t t e n t i v e l y to her t r o u b l e s , not minimizing the d i f f i c u l t y , not c r i t i c i z i n g or a d v i s i n g , tends t o induce a warm response i n the c l i e n t , l e a d i n g to a sense of being understood, which i s the deepest -22-bond i n e i t h e r personal or p r o f e s s i o n a l a s s o c i a t i o n s . 1 This i s the f i r s t p r o f e s s i o n a l bond between worker.and c l i e n t — t h e c l i e n t i s i n i t i a l l y assured by the worker's acceptance; she i s ~ f u r t h e r reassured by the worker's w i l l i n g n e s s to t r y to help her. I t i s w h i l e t h i s i n i t i a l bond i s developing that the worker f i n d s out what was the c l i e n t ' s i d e a i n coining f o r help. The worker t r i e s t o help her to v e r b a l i z e her reason f o r coming, not only because t h i s leads to understanding her own sense of d i f f i c u l t y , but a l s o because her request f o r help i s , i n her opi n i o n , the immediate point of contact. Progress can be made only i f the c l i e n t ' s purpose i s e a r l y made c l e a r , and the agency's resources and f u n c t i o n s e q u a l l y so. The worker makes i t e a s i e r f o r the c l i e n t by e x p l a i n i n g i n a general way the r o l e of the agency—what s e r v i c e s can be o f f e r e d . Thus, i n t h i s way, the o s t e n s i b l e request of the c l i e n t i s joine d w i t h the agency's f u n c t i o n and s e r v i c e . I n a d d i t i o n the c l i e n t w i l l f e e l that her coming to the c l i n i c i s understood. When d e s c r i b i n g h i s r o l e , the worker e x p l a i n s , whenever necessary, any s p e c i a l l i m i t a t i o n s of the agency f u n c t i o n and what other resources are a v a i l a b l e i n the com-munit y. For any e f f e c t i v e use of a service,, s t i l l more f o r any change i n a t t i t u d e s and behaviour, the c l i e n t needs to be en-couraged to put something of h e r s e l f i n t o the treatment process, to communicate what i s necessary by way of s o c i a l f a c t s , s o c i a l h i s t o r y and her f e e l i n g s , and to make an e f f o r t on her own be-h a l f , which i s u s u a l l y recognized and a c c r e d i t e d v e r b a l l y when-ever necessary i n the i n t e r v i e w . From the f i r s t moment, the T~. Annette G a r r e t t , op. c i t . , p. 1 9 . -23-worker supports honest efforts:vto p a r t i c i p a t e , to co-operate, and to work a c t i v e l y toward a s o l u t i o n . When d e a l i n g w i t h d i f -f i c u l t and p a i n f u l d e t a i l s a good dea l of backing and reinforce-ment may have t o be given, but without pressure or c u r i o s i t y . Always, however, the worker avoids r a i s i n g f a l s e hopes or g i v -ing f a l s e encouragement. Real assurance occurs from conveying to the c l i e n t that the s o c i a l worker i s i n t e r e s t e d i n the prob-lem and intends to t r y to help her, g e t t i n g the f e a r s r e l e a s e d r a t h e r than making her repress them and planning out concrete and immediate steps to take together. Treatment Methods From a::study of the e v o l u t i o n of case work concepts and case work treatment methods, i t i s noted t h a t present day concepts and methods are a combination o f p r i n c i p l e s and methods of case workers of e a r l i e r days. The methods were e a r l i e r de-f i n e d and red e f i n e d i n p r a c t i c e and d e f i n i t e i n t e r v i e w i n g methods have emerged as s k i l l s to help a c l i e n t through t r e a t -ment . In any area of treatment, there are u s u a l l y appropriate c l u s t e r s of b a s i c treatment methods depending on the problem, the aim, t r e a t a b i l i t y , agency f u n c t i o n , and other f a c t o r s , such as: the establishment of confidence; the r e d u c t i o n of anxiety by acceptance, support, and measures undertaken to assure an understanding of the problem and t o help the c l i e n t to meet i t ; the maintenance of focus on s p e c i f i c goals d e s i r e d by the c l i e n t , through shared steps i n e x p l o r a t i o n and the m o b i l i z a -t i o n of inner and outer resources; the support of c o n s t r u c t i v e defences and work w i t h the r e l a t i v e l y n o n - c o n f l i c t e d p a r t of - 2 4 -the i n t r a p s y c h i c aspects of the c l i e n t ' s p e r s o n a l i t y ; motivat-i n g t o st i m u l a t e growth and su b l i m a t i o n by arousing i n t e r e s t s , a p t i t u d e s and t a l e n t s . The worker undertakes to c l a r i f y obscure f e e l i n g s and a t t i t u d e s which, pre-conscious or p a r t i a l l y con-s c i o u s , vaguely d i s t u r b the c l i e n t , so as to enable her to have a b e t t e r understanding of the r o l e she i s p l a y i n g . U s u a l l y such c l a r i f i c a t i o n has the in t e n t to permit the expres s i o n of more f e e l i n g by the c l i e n t w i t h i n the r e l a t i o n s h i p , reducing the tensions of u n c e r t a i n t y , and thus to e n l i s t the h e a l t h i e r p a r t s of the p e r s o n a l i t y i n the s t r u g g l e . G i v i n g i n f o r m a t i o n may be necessary before the c l i e n t i s able to embark on a course or p l a n of a c t i o n . This l a t t e r technique i s an i n t e l l e c t u a l comprehension, although t h i s cannot be achieved without some f e e l i n g response. Case workers make cautious use of i n t e r p r e -t a t i o n , of e i t h e r s o c i a l or personal f a c t o r s and t h e i r i n t e r -a c t i o n , u s u a l l y employing techniques of c l a r i f i c a t i o n , support-i n g the ego w i t h i n the r e l a t i o n s h i p , w i t h l i t t l e p e n e t r a t i o n of defences unless negative and unusually d i f f i c u l t phases of r e s i s t a n c e and p a r t i c u l a r l y negative t r a n s f e r e n c e occur. The attempt to c l a r i f y Induces degrees of self-awareness at any l e v e l , but can achieve r e s u l t s only when the c l i e n t i s ready f o r i t . Premature attempts to penetrate defensive structures-w i l l be shrugged o f f i o r resented or w i l l arouse anxiety s t a t e s . Although changes i n f e e l i n g s and behaviour, e s p e c i a l l y of young c h i l d r e n , by r e l e a s i n g f e e l i n g s and c o r r e c t i n g the environment, are p o s s i b l e without conscious i n s i g h t , u s u a l l y same s e l f -awareness i s a concomitant of change. The t i m i n g of i n t e r p r e -t a t i o n i s important. S u p e r f i c i a l l a y e r s have to be worked -25-through aga i n and a g a i n b e f o r e a s s i m i l a t i o n takes p l a c e — e v e n i f n o t h i n g deeper i s attempted. The/methods d i s c u s s e d i n t h i s study are not n e c e s s a r i l y the only s k i l l s used by workers, and i t i s l i k e l y that t h i s l i s t may be incomplete. However, the methods are those which seem t o have come out of the development of case work, most of which are seen i n a p p l i c a t i o n as some of the s k i l l s of the s o c i a l case worker i n a c l i n i c a l s e t t i n g . Such tech n i q u e s as were observed may c o n c e i v a b l y r e a c h f u r t h e r d e f i n i t i o n and e l a b o r a t i o n as experience here a n d l i n other p l a c e s adds to the present knowledge. In a recent s t u d y 1 made at the Vancouver C h i l d Guidance C l i n i c , Mr. G e o f f r e y Glover has drawn up a c l a s s i f i c a t i o n of case work treatment methods; methods which have been f o l l o w e d •  r a t h e r c l o s e l y i n the present study. Mr. G l o v e r i d e n t i f i e s methods which seem to have emerged i n a study of the h i s t o r y of s o c i a l case work i n t e r v i e w i n g as "the encouragement to t a l k , moving w i t h the c l i e n t , g i v i n g i n f o r m a t i o n , g u i d i n g , m o t i v a t i n g , a i d i n g e x p r e s s i o n of f e e l i n g , a c c e p t i n g f e e l i n g , p e r s o n a l i t y s t r e n g t h e n i n g , c l a r i f y i n g , h o l d i n g to the frame of r e f e r e n c e , 2 r e c h a n n e l l i n g , i n t e r p r e t i n g , s e t t i n g l i m i t s . " Very e a r l y i n the e v o l u t i o n of case work i n t e r v i e w i n g , s o c i a l workers l e a r n e d to l i s t e n s e n s i t i v e l y t o the c l i e n t ' s request f o r h e l p . The c l i e n t i s i n i t i a l l y assured by the worker's acceptance; she i s f u r t h e r r e a s s u r e d by the worker's w i l l i n g n e s s to t r y to h e l p her. The worker, t h e r e f o r e , f i n d s out e a r l y what was the c l i e n t ' s reason f o r seeking h e l p . T~. Geoffrey Glover, "Case Work I n t e r v i e w i n g Methods In A C h i l d  Guidance S e t t i n g " , Master of S o c i a l .Work T h e s i s , U n i v e r s i t y of • B r i t i s h Columbia, 1951, p. 8.. i r \ J n * t l M , , p r e s e n t sJ l u d7 the term " s u p p o r t i n g " has been s u b s t i -t u t e d f o r Mr. G l o v e r 1 s term " p e r s o n a l i t y s t r e n g t h e n i n g ^ and - 2 6 -The worker t r i e s to encourage the c l i e n t to t a l k about her reason f o r coming, not only because t h i s w i l l l e a d to under-standing her own sense of d i f f i c u l t y , but w i l l o f f e r the c l i e n t a f a i r l y easy s t a r t i n g p o i n t . The worker, t h e r e f o r e , t r i e s to get the c l i e n t to d i s c u s s the s i t u a t i o n that l e d up t o her d e c i s i o n to come to the c l i n i c . Although u s u a l l y i t i s w e l l to l e t the c l i e n t t a l k without too much i n t e r r u p t i o n , e s p e c i a l l y at f i r s t , some questions are o f t e n necessary. Questions are u s u a l l y formed i n such a way that the c l i e n t i s encouraged t o d i s c u s s what to her seems important, u s u a l l y p o i n t i n g the way to her more fundamental a t t i t u d e s and d e s i r e s as w e l l as g i v i n g i n f o r m a t i o n about the t o t a l s i t u a t i o n and h e r s e l f . The worker encourages the c l i e n t whenever i t i s appropriate: perhaps by r e c o g n i z i n g w i t h her the d i f f i c u l t y i n v o l v e d i n speaking about the problem or the d i s c u s s i o n o f " h e r s e l f , or perhaps by remain-i n g s i l e n t . The worker moves w i t h the c l i e n t . The worker times h i s questions and responses, i n such a way as to meet the present needs of the c l i e n t . This s o r t of approach allows the c l i e n t to answer a general question i n her own way. She may not, how-ever, take up the d i s c u s s i o n at a l l , but r a t h e r t u r n i t o f f un-answered i f she chooses to do so. The c l i e n t ' s view of her im-mediate needs i s made use of, and the p a r t i c i p a t i o n gained by t h i s method i s o f t e n a strengthening i n f l u e n c e since the c l i e n t has a chance to take the i n i t i a t i v e i n d i s c u s s i o n . At the be-g i n n i n g of treatment the c l i e n t i n d i c a t e s where d i s c u s s i o n s s i m i l a r l y , " f o c u s s i n g " i s used i n s t e a d of "holding t o the frame of reference". In order to avoid confusion as to the meaning of d i f f e r e n t - t e r m s r e l a t i n g to case work treatment methods, methods are i d e n t i f i e d d e s c r i p t i v e l y . -27-should begin by t a l k i n g of a s p e c i f i c problem. When t h i s has been dealt with the c l i e n t often leads the discussion into more fundamental causes of her d i f f i c u l t y or other areas of tension, u n t i l the chief area of disturbance has been uncovered and dealt with. If the c l i e n t understands the reason f o r moving on from one area of discussion to another, and i f the case worker starts from the point where the c l i e n t i s , does not force the tempo, follows s e n s i t i v e l y the f e e l i n g tones, then the c l i e n t w i l l be able to move ahead without the worker-client r e l a t i o n s h i p being adversely affected; on the contrary, the c l i e n t w i l l tend to appreciate what seems to her to be i n t e l l i g e n t interest and con-cern. What f i n a l l y convinces the c l i e n t , i f she i s at a l l well-disposed toward treatment, i s recognition that her needs are understood and that the worker grasps what i s r e a l l y involved both i n the psychological and the s o c i a l areas of d i f f i c u l t y . In general, the worker i s responsive to points of stress—help- r -ing the c l i e n t to bring out rather than to keep back relevant and s p e c i f i c f e e l i n g s . This i s e s s e n t i a l l y what gives an i n -terview "movement", as i t i s c a l l e d . However, t h i s method places a burden on a c l i e n t who has d i f f i c u l t y i n v e r b a l i z i n g her desire for help. The trained worker i s able to read the true meaning of a c l i e n t ' s entire system of expression including speech, mannerisms and bodily tensions. His s e n s i t i v i t y to these signs helps him to decide when i t i s best to do something for the c l i e n t , and when he should encourage the c l i e n t to act f o r h e r s e l f . Workers f e e l that the c l i e n t has the right to determine the course of her -28-own l i f e ; to p a r t i c i p a t e i n treatment or not, as she pleases. Giving information may he necessary before the c l i e n t i s able to embark on a course or plan of action. Information may be i n r e l a t i o n to the c l i e n t ' s needs and f e e l i n g s , her problem, information, about herself, the treatment process, and resources outside the agency. In c h i l d guidance c l i n i c s , the worker's capacity for transmitting with s e n s i t i v i t y the information about a child's behaviour to the parent i s of primary Import-ance. The effectiveness of work with a parent depends to a great extent on giving information when the c l i e n t i s ready f o r i t and i n a form that can be used by her. Guiding during an interview has been a technique that has always been used by s o c i a l workers. However, the method has changed as the whole concept of s o c i a l work has changed. In the 1920's, the worker's guiding was of a passive kind—keeping the c l i e n t on the subject of immediate need. Now the worker takes more active p a r t i c i p a t i o n i n the interview. Aside from conveying to the c l i e n t that he i s interested i n the problem and intends to try to help her, getting the fears released rather than making her repress them, the worker now plans con-crete and immediate steps to take with the c l i e n t . Motivating describes a p a r t i c u l a r act i n treatment by the worker, not only encouraging the c l i e n t to continue and p a r t i -cipate, but also indicating to her the d i r e c t i o n treatment and personality growth can take. This i s an i n t e r p r e t a t i o n of the process of treatment based on what has been achieved and what r e a l i s t i c a l l y can be expected to take place i n personality growth. -29-A i d i n g the e x p r e s s i o n of f e e l i n g h e l p s the c l i e n t to c l a r i f y her t h i n k i n g about her s i t u a t i o n and h e r s e l f ; h e l p s to reduce t e n s i o n s that r e s u l t from u n c e r t a i n t i e s ; h e l p s to e n l i s t the h e a l t h i e r p a r t s of her p e r s o n a l i t y i n the s t r u g g l e f o r a b e t t e r and h a p p i e r adjustment. Long ago i n the development of case work treatment methods, i t was noted that an anxious c l i e n t who expresses her f e e l i n g s t o someone able to understand her a n x i e t y , who can remain calm, i n c r e a s e s the c l i e n t ' s con-f i d e n c e once the p r e s s u r e of f e e l i n g has been r e l i e v e d . 1 In advanced stages of treatment a c l i e n t can be helped to " r e - f e e l " emotional experiences of the past by d i s c u s s i n g them i n the i n t e r v i e w w i t h , or without understanding of t h e i r r e a l meaning. With the worker's support, the c l i e n t may be h e l p e d to see p a i n f u l memories of the past i n t h e i r t r u e meaning. Even i f the c l i e n t does not achieve understanding of h e r s e l f , r e - f e e l -i n g i n the presence of s t r o n g emotional support helps to over-come o l d f e a r s . The sepax'ate act of a c c e p t i n g f e e l i n g , which i s e i t h e r p o s i t i v e or n e g a t i v e , i s d i f f e r e n t from the measures taken to a i d e x p r e s s i o n of f e e l i n g . Workers n o t i c e d i n the l a t e r 1930's, as the importance of f e e l i n g s were c o n t i n u a l l y empha-s i z e d i n case work i n t e r v i e w i n g , t h a t the c l i e n t seemed to make d e f i n i t e progress i n treatment a f t e r h a v i n g .expressed p o s i -t i v e or n e g a t i v e f e e l i n g s i n r e l a t i o n t o the problem. Her ex-p r e s s i o n does not b r i n g down on h e r the worker's c r i t i c i s m , blame or p r a i s e ; she can be h e r s e l f s a f e l y . The p e r m i s s i v e n e s s of the worker seems t o d i r e c t the a t t e n t i o n of the c l i e n t t o -ward her f e e l i n g and she i s o f t e n able t o understand i t i n a TT Florence H o l l i s , S o c i a l Case Work i n P r a c t i c e , Family Welfare A s s o c i a t i o n of America, New York, N.Y., 1939, p. 302. -30-s t a t e uncomplicated'by the need to s a t i s f y another person. The method i s of v a l u e where the worker h e l p s a c l i e n t who has f a i l e d t o make f u l l use of i n d i r e c t and s o c i a l l y a c c e p t a b l e methods of e x p r e s s i o n . The c l i e n t i s h e l p e d to express v e r -v a l l y her s o c i a l l y unacceptable f e e l i n g s , r e l i e v i n g the p r e -sures of impulses b u i l t up by r e p r e s s i o n , and the worker i n -d i c a t e s by a t t i t u d e and words that i t i s a l l r i g h t t o do so i n t h i s s e t t i n g . Supporting i s a process which c o n c e n t r a t e s the a t t e n t i o n of the c l i e n t on her present p e r s o n a l i t y s t r e n g t h s . P o s i t i v e elements i n the c l i e n t ' s s i t u a t i o n are used as bases f o r r e -assurance; that the c l i e n t does, i n f a c t , possess some qu a l i t i e s : ; that are t o be admired. In the b e g i n n i n g stage of treatment . i t i s sometimes d i f f i c u l t t o f i n d such f a c t o r s ; when t h i s occurs-, reassurance i n terms of the treatment s i t u a t i o n i t s e l f can prove to be a good technique. The c l i e n t can be t o l d t h a t by coming t o the c l i n i c and t r y i n g t o do something about her d i f -f i c u l t i e s , she i s showing s t r e n g t h . The same p r i n c i p l e s that are used i n g i v i n g assurance to the c l i e n t apply i n g i v i n g en-couragement. E x p r e s s i o n s of confidence and encouragement are always based on r e a l i t y . A c o r o l l a r y of t h i s technique i s the acceptance of the c l i e n t ' s p e r s o n a l i t y weaknesses. As a n x i e t y d i m i n i s h e s , the c l i e n t g a i n s s t r e n g t h to handle immediate s i t u -a t i o n s , and the experience of more adequate f u n c t i o n i n g becomes i n / l i t s e l f a growth p r o c e s s . C l a r i f y i n g i s the attempt made by the worker to h e l p the c l i e n t understand her obscure f e e l i n g s and a t t i t u d e s , which, pr e - c o n s c i o u s o r p a r t i a l l y c o n s c i o u s , vaguely d i s t u r b her. -31-I n g e n e r a l , whenever the c l i e n t e x p r e s s e s a c o n f l i c t o r a dilc••-emma, t h e w o r k e r p i c k s i t up and r e s t a t e s i t , u s i n g the c l i e n t ' s own w o r d s . The w o r k e r m i g h t t h e n r e l a t e t h e a t t i t u d e , f e e l i n g o r o p i n i o n t o r e a l i t y f a c t o r s , d e p e n d i n g o n t h e c l i e n t ' s c a p a -c i t y t o a c c e p t t h e f a c t s . O f t e n , t h e mere v e r b a l i z a t i o n o f t h e c l i e n t ' s t r u e m e a n i n g i s s u f f i c i e n t t o h e l p h e r a c h i e v e i n s i g h t i n t o u n r e a l i s t i c b e l i e f s and a t t i t u d e s . T h i s has t h e e f f e c t o f f u r t h e r c l a r i f y i n g t h e p r o b l e m and may l e a d t o a s h a r e d f o r m u -l a t i o n o f a p l a n o f a c t i o n . The c l i e n t i s l e f t f r e e t o a c c e p t t h e w o r k e r ' s v e r b a l i z a t i o n o r n o t , d e p e n d i n g u p o n h e r own s t a t e o f r e a d i n e s s . F o c u s s i n g i s a method w h i c h means d e c i d i n g what t o do i n t h e l i g h t o f t h e c u r r e n t p r o b l e m . The f o c u s may change as t r e a t m e n t p r o g r e s s e s . The c l i e n t ' s own d e f i n i t i o n o f h e r need may change as t e n s i o n s a r e s u c c e s s f u l l y w o r k e d t h r o u g h , and new ones a r e c o n s i d e r e d . The new a r e a o f t e n s i o n becomes t h e n e w / f o c u s d u r i n g t h e d i s c u s s i o n s . N o r m a l l y , f o c u s s i n g i s p o s s -i b l e o n l y when t h e r e i s a good r e l a t i o n s h i p w i t h t h e c l i e n t . Where t h e r e i s a p o o r r e l a t i o n s h i p , t h e c l i e n t w i l l be u n w i l l -i n g t o h e l p f o c u s t h e t r e a t m e n t a i m . R e c h a n n e11 i n g i s a method w h i c h h a s as i t s p u r p o s e t h e aim t o h e l p t h e c l i e n t t o be as aware as p o s s i b l e o f t h e ways i n w h i c h she i s r e a c t i n g t o t h e r e a l i t y f a c t o r s i n h e r s i t u a t i o n a n d , p e r h a p s , c o n t r i b u t i n g t o t h e p r o b l e m , and t o h e l p h e r t o r e d i r e c t t h e s e i m p u l s e s t o more a c c e p t a b l e ways o f b e h a v i n g . A f t e r t h e c l i e n t h a s b e e n h e l p e d t o s o r t out t h e i s s u e s i n h e r s i t u a t i o n , t o c l a r i f y h e r p r o b l e m and h e r c o n f l i c t s w i t h r e a l i t y , t o d i s c u s s t h e f e a s i b i l i t y o f v a r i o u s c o u r s e s o f -32-a c t i o n , the worker h e l p s her r e a l i s t i c a l l y t o assume respon-s i b i l i t y of making a choice of the b e s t means of accomplishing a r e d i r e c t i o n of her p r e v i o u s unacceptable impulses. The case worker makes ca u t i o u s use of i n t e r p r e t a t i o n , of e i t h e r s o c i a l or p e r s o n a l f a c t o r s and t h e i r i n t e r a c t i o n , u s u a l l y employing techniques of c l a r i f i c a t i o n , and s u p p o r t i n g the ego w i t h i n the r e l a t i o n s h i p , w i t h l i t t l e p e n e t r a t i o n o f defences u n l e s s negative and u n u s u a l l y d i f f i c u l t phases of r e -s i s t a n c e and p a r t i c u l a r l y n e g a t i v e t r a n s f e r e n c e occur. No ab-s o l u t e l i n e s can be drawn, s i n c e the c l i e n t p e r mits h e r s e l f v a r y i n g degrees of i n s i g h t i n any treatment s i t u a t i o n . The attempt to i n t e r p r e t t o a c l i e n t induces degrees of s e l f -awareness at any l e v e l , but can achieve r e s u l t s only when the c l i e n t i s ready f o r i t . I n t e r p r e t i v e case work i s used to l e a d the c l i e n t gradu-a l l y i n t o g r e a t e r awareness of the nature and extent of her f e e l i n g s , and of the unconscious m o t i v a t i o n s that u n d e r l i e h e r a c t i o n s . Relevant c h i l d h o o d memories are r e c a l l e d and b l o c k i n g emotions d i s c h a r g e d . I n t e r p r e t a t i o n i s most e f f e c t i v e i f i t . i s c l o s e l y r e l a t e d to the " c e n t r a l problem" df the c l i e n t as i t a f f e c t s her r e a l i t y adjustment. T h i s " c e n t r a l problem" i n t e r -p r e t a t i o n can be most e f f e c t i v e l y done by case workers from a s m a l l i n c i d e n t or episode from the c l i e n t ' s r e a l l i f e experience as t o l d by h e r . The small episode i s u s e f u l f o r i n t e r p r e t a t i o n when i t c o n t a i n s and i l l u s t r a t e s the c l i e n t ' s f e e l i n g s and be-h a v i o u r as a c t i v a t e d by h e r c e n t r a l problem. 1 The emotional r e l a t i o n s h i p between the c l i e n t and the case worker should not TI I n t e r p r e t a t i o n should, of course, not be c o n f i n e d to the " s m a l l i n c i d e n t " , -but should have a c e n t r a l theme corresponding to the c e n t r a l problem. -33-be interpreted as long as the relationship i s a p o s i t i v e one, I m c e r t a i n situations the worker finds itLnecessary to set  l i m i t s i n the treatment process. Workers i h some settings .make use of t h i s technique i n defining sharply the area of help available i n the agency. This i s a concept of strengthening the w i l l and meeting r e a l i t y by accepting the limits:: of agency f u n c t i o n . 1 .The groupoof workers c a l l i n g themselves the Dynamic School also make use of t h i s method i n noting how the c l i e n t uses the l i m i t s around the time and place of the interview, how.-/ she reacts to giving required information f o r the s o c i a l h istory, and her acceptance of such l i m i t a t i o n s as are imposed,in a re-la t i o n s h i p with a professional person. Besides factors named above, children i n the interviewing s i t u a t i o n are l i m i t e d i h the amount of damage they can do to the equipment, and the violence they can express on the worker's person. The method i s of value with children whose needs'in t r a i n i n g are i n t h i s area. Immature adults who have never learned to use l i m i t s and those with special problems i n r e l a t i o n to authority are also able to benefit from l i m i t s set within a treatment r e l a t i o n -ship. Insight case work i s aimed, at achieving a change i n the ego by developing the c l i e n t ' s insight into her d i f f i c u l t i e s and increasing the a b i l i t y of the ego to deal with them through the emotional experience i n the transference s i t u a t i o n . Interview-ihg'designed for insight into the unconscious determinants of behaviour i s reserved f o r those workers with special and, indeed, rigorous t r a i n i n g . Fortunately, moderate changes may be e f f e c t -ed by s i t u a t i o n a l adjustments, case work help on a conscious 1. The.Philadelphia School was the f i r s t to draw attention to the possible use of agency function i n t h i s way. -34-l e v e l , c l a r i f i c a t i o n of r e a l issues, without the goal of " i n -sight ", .which may be gained only ,in a special sort of emotional experience. In insight case work, the transference r e l a t i o n s h i p i s used to help the c l i e n t understand her i r r a t i o n a l impulses, how they arose i n the past and how the present s i t u a t i o n d i f f e r s , so that she may modify her behaviour accordingly. Insight i s accompanied by " r e - f e e l i n g " i n much the same way as the original, f e e l i n g e l i c i t e d a response. The transference must be c o n t r o l l -ed as to i n t e n s i t y , however, so as not to i n t e r f e r e with the c l i e n t ' s judgement and co-operation. The transference may be interpreted when the c l i e n t ' s negative or p o s i t i v e attitudes toward the worker are used as resistance to going on toward the gaining of further insight or a greater maturity i n her r e a l l i f e s i t u a t i o n . In summary, the interview can motivate, can teach, can secure information, can help c l i e n t s bring out things which are bothering them. The Interview provides one of the best ways of observing a person's behaviour. It i s a good way to get facts about a p a r t i c u l a r sett of circumstances; i t i s almost the only way to achieve an understanding of attitudes and f e e l i n g s — t h e unique reaction of the i n d i v i d u a l to her s i t u a t i o n . Because the case i s made up of inner as well as outer factors, the person's a b i l i t y to t a l k about her feelings, as well as about the object-ive facts of her s i t u a t i o n , heightens the importance of the i n -terview. It would be hard for the case worker to d i f f e r e n t i a t e what he learns through the ear from that which he learns through the eye. Although a worker can observe without interviewing, he - 3 5 -can r a r e l y i n t e r v i e w without o b s e r v i n g . M o t i v a t i o n i s o f t e n un-c o n s c i o u s , but the c l i e n t admits the worker to at l e a s t p a r t i a l understanding of h e r emotional problems by her tone, her a t t i -tudes, her behaviour, and by h e r manner of t e l l i n g about her experience; by her . s i l e n c e s , d e n i a l s , p r o j e c t i o n s , and other defences. I n t e r v i e w i n g and the accompanying o b s e r v a t i o n , t h e r e -f o r e , are r e l i e d upon to provide much of the case d a t a . Repeat-ed i n t e r v i e w s .of f e r r e l i a b l e data, which the s i n g l e i n t e r v i e w can r a r e l y achieve. The o b s e r v a t i o n of the c l i e n t ' s b e h aviour i n the i n t e r v i e w i t s e l f , her f e e l i n g s of adequacy or dependency, her f e a r s and i r r i t a t i o n , compliance or a g g r e s s i o n , her way of r e l a t i n g h e r s e l f to the worker and the agency, and s i g n s of s t r e n g t h or weakness are means toward a p p r a i s a l o f . h e r s o c i a l f u n c t i o n i n g and c a p a c i t y f o r a d a p t a t i o n . A number of attempts have been made from time to time to c l a s s i f y the c h i e f methods of treatment. However, the t e r m i n -ology of most attempts i s not p r e c i s e , and, consequently t h e r e i s r e s u l t i n g c o n f u s i o n . However, almost a l l w r i t e r s agree on the e s s e n t i a l a t t r i b u t e of treatment: the aim i s b e t t e r s o c i a l f u n c t i o n i n g and b e t t e r p e r s o n a l adjustment or a d a p t a t i o n . In a l l case work, e s p e c i a l l y when i t s aim i s t h e r a p e u t i c , the prob-lem must be c l e a r l y d e f i n e d , the c l i e n t ' s responses and wish f o r s e l f - i n v o l v e m e n t must be t e s t e d , the area f o r treatment must be determined, and the d e s i r e d goal decided upon. The f i r s t que ac-t i o n i s always, "What i s to be done?" I t i s because of t h i s "what i s to be done?" that an attempt has been made to d e f i n e some- of the more common i n t e r v i e w i n g methods emerging, from sev-e r a l decades of case work p r a c t i c e . The f a c t t h a t p a r t i c u l a r methods have "been s i n g l e d out should not suggest t h a t they are ever i s o l a t e d completely i n the dynamics of the i n t e r v i e w . On the c o n t r a r y , methodology i s only one of the means by which the case work i n t e r v i e w achieves i t s purpose. Methods alone are r e c o g n i z e d as i n e f f e c t i v e u n t i l they are a p p l i e d by the worker., who i s by nature warm, sympathetic and s i n c e r e . The aim of de-f i n i n g methods i s to h e l p give a b e t t e r s e r v i c e . In the f o l l o w i n g chapter, the study proceeds t o d i s c u s s the ways i n which the case work i n t e r v i e w e r c o n t r i b u t e s t o s e r -v i c e s g i v e n by the C h i l d Guidance C l i n i c in. Vancouver, and s p e c i f i c a l l y to emphasize how d i f f e r e n t case work treatment methods are more s u c c e s s f u l w i t h c e r t a i n k i n d of m o t h e r s , ; t h a t i s , how the p e r s o n a l i t y of the mothers determines^ t o arconsid-e r a b l e extent, the l e v e l of case work h e l p that they can use. -37-Chapter 3 Interviews With Mothers Because of the nature of c h i l d guidance, c l i n i c s p r o v i d e s e r v i c e s c h i e f l y f o r c h i l d r e n whose d i f f i c u l t i e s are l a r g e l y -a t t r i b u t a b l e to maladjustments i n the p a r e n t - c h i l d r e l a t i o n s h i p and whose parents want a s s i s t a n c e w i t h these problems. The f i r s t of these c r i t e r i a l e a d s c h i l d guidance c l i n i c s to exclude most cases of feeble-mindedness and n e u r o l o g i c a l d i s o r d e r and those i n which' there i s gross s o c i a l p a t h o l o g y . 1 The second c r i t e r i o n d i f f e r e n t i a t e s these c l i n i c s from many of those con-nected w i t h h o s p i t a l s , s c h o o l s , c o u r t s , and p u b l i c w e l f a r e de-partments, s i n c e the l a t t e r f r e q u e n t l y f o l l o w the p o l i c y of t r e a t i n g the c h i l d r e n without r e q u i r i n g that p a r e n t s themselves have r e g u l a r i n t e r v i e w s w i t h a s o c i a l worker. These c r i t e r i a are not r i g i d l y h e l d t o , but even i n excep-t i o n a l cases at l e a s t one of them i s l i k e l y to be met. C h i l d guidance c l i n i c s , f o r example, t r e a t some c h i l d r e n whose i n t e l -p l i g e n c e i s r a t h e r l i m i t e d , o;r-who s u f f e r from n e u r o l o g i c a l d i s -o r ders i f the d i f f i c u l t i e s appear to be complicated by adverse p a r e n t a l a t t i t u d e s and the parents d e s i r e h e l p i n improving t h e i r r e l a t i o n s w i t h the c h i l d r e n . Again, some a d o l e s c e n t s whose d i f f i c u l t i e s stem from adverse home s i t u a t i o n s are t r e a t e d without much r e f e r e n c e t o the p a r e n t s , e i t h e r because the par-ents are not i n t e r e s t e d i n working w i t h the c l i n i c or are too TT Many parents b r i n g feeble-minded c h i l d r e n t o the c l i n i c f o r psychometric t e s t i n g . These parents are a l s o helped t o accept the l i m i t a t i o n s of these c h i l d r e n , and to l e a r n b e t t e r ways of h a n d l i n g them. 2. Case work i n c h i l d guidance c l i n i c s appears as l i k e l y to be s u c c e s s f u l w i t h c h i l d r e n of d u l l normal i n t e l l i g e n c e as w i t h those who are above average. (Few c h i l d r e n w i t h I.Q.'s under 80 are g i v e n d i r e c t treatment.) See L i l l i a n Glassman, "Is D u l l Normal I n t e l l i g e n c e a C o n t r a - I n d i c a t i o n f o r Psychotherapy?" SMith C o l l e g e S t u d i e s i n S o c i a l Work, 13:275-298, March 1943.The -38-maladjusted to b e n e f i t from s o c i a l case work. Then, too, i n co - o p e r a t i o n w i t h s o c i a l agencies, c h i l d guidance c l i n i c s t r e a t c h i l d r e n who are not l i v i n g w i t h t h e i r p a r e n t s . In such cases, however, the c h i e f d i f f i c u l t i e s to be s t r a i g h t e n e d out are the traumatic experiences of s e p a r a t i o n from them; thus, even t h i s k i n d of case meets one of the two c r i t e r i a . W i t h i n these l i m i t a t i o n s , c h i l d guidance c l i n i c s have as p a t i e n t s c h i l d r e n who d i s p l a y a v e r y wide v a r i e t y of behaviour and p e r s o n a l i t y d i s o r d e r s . The symptoms that cause the parents concern are of many types: a g g r e s s i v e , u n c o n t r o l l a b l e b e h a v i -our; nervousness, s e n s i t i v i t y , f e a r s , e x c e s s i v e shyness, and o t h e r d i f f i c u l t i e s i n r e l a t i n g to people; v a r i o u s kinds of s c h o o l maladjustment; p h y s i c a l d i s o r d e r s without d i s c o v e r a b l e organic bases; d e l i n q u e n c i e s of v a r i o u s kinds; marked p e c u l i -a r i t i e s of behaviour and p e r s o n a l i t y . These and a host of other complaints (t h a t c h i l d r e n are "too good" or that they are "too bad"; t h a t they appear to be s i c k or t h a t , out of robust h e a l t h , they d r i v e t h e i r parents to d i s t r a c t i o n ) b r i n g c h i l d r e n to a c h i l d g u i d a n c e . c l i n i c . Reasons f o r S e l e c t i n g the Present Sample When a c h i l d i s brought to the c l i n i c , he i s u s u a l l y ac-companied by h i s mother. In a few i n s t a n c e s , the f a t h e r a l s o comes to the c l i n i c w i t h the c h i l d . Because s o c i a l workers have-been, f o r some years p a s t , concerned w i t h the k i n d of case work h e l p r e c e i v e d by parents of these c h i l d r e n , i t seemed a p p r o p r i a t e to analyze a sample of the cases that had been t r e a t e d at the c l i n i c . T h i s s o r t j o f a n a l y s i s seemed e s p e c i a l l y f i n d i n g s of t h i s study have been 'confirmed by two other i n v e s t i -g a t i o n s conducted by students of the Smith C o l l e g e School of S o c i a l Work. - 3 9 -p e r t i n e n t s i n c e s o c i a l workers have n o t i c e d , i n recent y e a r s , that a new t r e n d seems to be i n f l u e n c i n g the f u n c t i o n of t h i s " c h i l d r e n ' s agency":' parents seem t o be r e c e i v i n g more case work h e l p than do t h e i r c h i l d r e n . Aside from d e t e r m i n i n g whether or not there a c t u a l l y i s a s h i f t i n emphasis i n case work pracr-t i c e at the c l i n i c , s o c i a l workers are a l s o i n t e r e s t e d i n know-i n g more about the k i n d or l e v e l of treatment these a d u l t clients'.-r e c e i v e . I t i s the purpose of the present study to d i s c u s s these two f a c t o r s — e x t e n t of parent p a r t i c i p a t i o n , and l e v e l of t r e a t -ment, emphasis b e i n g p l a c e d on the l a t t e r f a c t o r . Because the number of i n t e r v i e w s h e l d w i t h f a t h e r s i n 1950 was so small (11 per cent of the t o t a l ) , the study i s concerned only w i t h the mothers of the c h i l d r e n brought to the c l i n i c ; c h i l d r e n brought because of problems of one s o r t or another, or f o r psychometric t e s t i n g . Reasons f o r R e f e r r a l The p r i v a t e cases of mothers of p r e - s c h o o l c h i l d r e n f o r the one year p e r i o d , 1950, can be grouped i n f o u r d i v i s i o n s a c c ord-i n g to reason f o r r e f e r r a l . The l a r g e s t group of cases (38 per cent) was r e f e r r e d because of d i f f i c u l t i e s i n s o c i a l adjustment at home, at k i n d e r g a r t e n or i n the community. T h i s d i v i s i o n was broken down i n t o g eneral and s p e c i f i c s o c i a l l y unacceptable be-h a v i o u r such as temper tantrums, b u l l y i n g , d e s t r u c t i v e n e s s , bragging, showing o f f , l y i n g , s t e a l i n g , and p r e c o c i o u s sex a c t i v i t y . The second group, r e f e r r e d because of p e r s o n a l i t y r e a c t i o n s (30 per cent) i n c l u d e d s e c l u s i v e n e s s , t i m i d i t y , sen-s i t i v e n e s s , f e a r s , e x c e s s i v e i m a g i n a t i o n , stubbornness, r e s t l e s s -ness, s e l f i s h n e s s , o v e r - a c t i v i t y and u n p o p u l a r i t y w i t h o t h e r -40-c h i l d r e n . The t h i r d group was c l a s s i f i e d as habit formation (7 per cent) and included s l e e p i n g and e a t i n g d i f f i c u l t i e s , speech di s t u r b a n c e s , n a i l b i t i n g , masturbation, prolonged bed we t t i n g and s o i l i n g , and thumb sucking. The f o u r t h d i v i s i o n was comprised of c h i l d r e n r e f e r r e d f o r psychometric t e s t i n g or men-t a l e v a l u a t i o n (25 per c e n t ) . The s o c i a l workers at the Van-couver C h i l d Guidance C l i n i c i n 1950 devoted only 31 per c:ent of f u l l s c a l e i n t e r v i e w s to the c h i l d r e n who were brought to the c l i n i c ; 58 per cent of the int e r v i e w s were w i t h the mothers, and 11 per cent w i t h the f a t h e r s . Table 1 Interviews Held With C h i l d , Mother, Father (Sample Group) Person. Interviews per person o v e r T o t a l T o t a l Interviewed 1 2 3 4 5': 6 7 8 9 10 10 i n t e r -views Per-sons C h i l d 5 n 6 - 2 - 1 - l l 4 131 31 Mother 10 3 3 8 1 4 - l 10 247 ' 40 Father 15 6 - - 3 1 - - - - - 48 25 T o t a l Fre-quency of Interviews 30 20 9 0 13 2; 0 l 2 14 426 96 T o t a l Num-ber I n t e r -views 30 40 27 0 65 L2 35 0 9 20 140 426 • 96 Interviews w i t h Mothers The s o c i a l worker i n the c l i n i c a l s e t t i n g has been able t o use medicine's more f o r m a l i z e d system :iof d i a g n o s t i c study and treatment w i t h f l e x i b i l i t y , b r i n g i n g from the welfa r e agency the idea that case e v a l u a t i o n i s a continuous process which might change as f u r t h e r i n f o r m a t i o n was brought to bear on the problem and, f u r t h e r , the d i a g n o s t i c process could be continued even a f t e r formal treatment had begun since new in f o r m a t i o n was bound -41-Table 2 Frequency of Interviews i n eaoh Case Shown by Problem or Reason fo r Referral Problem or Frequency of .] Interviews - . reason for r e f e r r a l Weekly Less Than Once Weekly Incomplete Information Total 1 D i f f i c u l t y i n s o c i a l adjustment 4 ' 44 ' 7 15 11 Personality reactions — 7 5: 12 111 Habit disorder 1 1 1 3 IV Psychometric t e s t i n g 2 5 3 10 .. Total 7 17 16 40 to be uncovered which would influence evaluation. Treatment was more of a dynamic than a s t a t i c process; rather than be-ginning at some d e f i n i t e point a f t e r the diagnostic conference, treatment was actually -yxler way as soon as the c l i e n t sensed the influence of the worker i n a face-to-face contact. At the same time, the system of diagnostic study and treatment x^ ras a d e f i n i t e asset i n that i t allowed the whole c l i n i c a l team to share r e s p o n s i b i l i t y f o r diagnosis, to give the worker carry-ing out -treatment the benefit of d i f f e r e n t professional points of view. The fact that the f i r s t interviews were aimed at gaining enough information f o r a diagnostic conference also tended to give d i r e c t i o n to interviewing. During the face-to-face interview which usually took place on the average of once every two weeks, a worker helped the c l i e n t to bring out information pertinent to the problem. On the basis of his di r e c t observation of the c l i e n t ' s mannerisms, - 4 2 -a t t i t u d e s and f eelingsp around the I n f o r m a t i o n brought out, along w i t h such i n f o r m a t i o n as might come from other sources, persons or documents the c l i e n t had made a v a i l a b l e , a worker would make a t e n t a t i v e e v a l u a t i o n . Such t h i n k i n g as the worker might do about the case would be added to by the base work s u p e r v i s o r , and ©ther c l i n i c a l p ersonnel would be a v a i l a b l e f o r c o n s u l t a -t i o n i f a s p e c i a l i z e d p o i n t of view was needed. The d i a g n o s t i c p r o c e s s under c l i n i c a l o r g a n i z a t i o n i n -c l u d e s p r e p a r a t i o n of a s o c i a l h i s t o r y , the p h y s i c a l examination, p s y c h o l o g i c a l and p s y c h i a t r i c examinations, and the d i a g n o s t i c conference. The s o c i a l h i s t o r y drawn up by the worker i s an attempt to present a v i v i d p i c t u r e of the c h i l d l i v i n g w i t h h i s p a r e n t s or f o s t e r p a r e n t s , i n h i s home and community.. As the worker prepared the s o c i a l h i s t o r y over s e v e r a l i n t e r v i e w s , the more s u p e r f i c i a l a spects of. treatment were o f t e n s u p p l i e d , e s p e c i a l l y w i t h a d u l t s . The i n i t i a l p e r i o d took on s p e c i a l meaning i n view of the worker's c a r e f u l l u s e of r e l a t i o n -ship i n treatment. He made a conscious e f f o r t t o set up a good r e l a t i o n s h i p w i t h the c l i e n t by demonstrating h i s d e s i r e to h e l p . E a r l y c l a r i f i c a t i o n and m o t i v a t i n g was undertaken i n order t o give as soon a s , p o s s i b l e a c o n c e p t i o n of the h e l p a v a i l a b l e and how i t might best be used. Where f e a s i b l e , the c l i e n t was encouraged to t a l k from the outset i n order to b r i n g out f a c t s , to g a i n a f u l l e r e x p r e s s i o n o f fundamental a t t i t u d e s and f e e l i n g s around the problem, as w e l l ' a s to h e l p the worker gauge the depth of the i n d i v i d u a l ' s p e r s o n a l i t y d i s t u r b a n c e . I n f o r m a t i o n was sometimes g i v e n the c l i e n t to meet immediate needs i n the s i t u a t i o n ; t h i s o f t e n took the form -43-of p r a c t i c a l suggestions for dealing with a child's unaccept-able behaviour. While the worker noted c a r e f u l l y the order and development the c l i e n t gave to the discussion, he encouraged p a r t i c i p a t i o n and i n i t i a t i v e i f the c l i e n t could benefit by i t . . When expressions of negative f e e l i n g were made the worker i n -dicated acceptance. Support was given i n r e l a t i o n to need, but on the more s u p e r f i c i a l l e v e l s , and without the sharpness of focus on fundamental issues which would l a t e r be added by the diagnostic conference. Table 3 Cases Showing Number of Interviews Held A f t e r Diagnostic Conference by Problem or Reason f o r Referral Problem or reason for r e f e r r a l Interviews a f t e r conference 0 1 to 5 6 to 10 11 to 15 over i 2 _ Total 1 D i f f i c u l t y i n soci a l adjustment 11 Personality reaction 111 Habit disorder IV Psychometric test ing 8 4 2 0 3 1 15 12 3 10 Total 15 13 8 40 The importance of t h i s early period i n interviewing was clear i n the study of the private cases f o r 1950 which indicated that 38 per cent of the 40 cases discontinued t h e i r contact with the c l i n i c immediately a f t e r diagnostic.conference. Rea-sons for discontinuing were often related s p e c i f i c a l l y to the nature of the problem. Some c l i e n t s decided early that they were unable to make good use of the service given by the c l i n i c . They were helped to thi s decision by the xvorker's c l a r i f i c a t i o n -44-of d i s c u s s i o n and h o l d i n g to the frame of r e f e r e n c e . Others found that i n t h i s short contact the worker was able to g i v e e x a c t l y the i n f o r m a t i o n needed to handle the problem, or was able t o help her to s u f f i c i e n t u n derstanding or acceptance of f a c t o r s which c o u l d not be changed. A number of mothers i n d i -cated that they came to the c l i n i c f o r h e l p at a time of momen-t a r y weakness i n h a n d l i n g t h e i r a f f a i r s . With the o p p o r t u n i t y t o t a l k out emotional t e n s i o n s to an a c c e p t i n g person, they were b e t t e r able to see t h e i r problem i n p e r s p e c t i v e and to handle i t without f u r t h e r h e l p . Seventeen per cent of t h i s group were r e f e r r e d f o r psycho-me t r i c t e s t i n g and d i s c o n t i n u e d e i t h e r because they had obtained the i n f o r m a t i o n sought, c o u l d not get the k i n d of h e l p they d e s i r e d , or were unable to b e n e f i t f u r t h e r from c l i n i c a l s e r -v i c e s . Table 4 Cases Showing Number of Interviews Held Before the D i a g n o s t i c Conference by Problem or Reason f o r R e f e r r a l Problem or reason f o r Interviews Before Conference r e f e r r a l 1 t o 5 6 to 10 T o t a l 1 D i f f i c u l t y i n s o c i a l adjustme nt 13 2 15 11 P e r s o n a l i t y r e a c t i o n s 12 - 12 111 Habit d i s o r d e r s 3 - 3 IV Psychometric t e s t i n g 10 - 10 T o t a l 38 2 40 The s i z e of the group of cases which r e c e i v e d short-term -45-treatment or l e s s i s q u i t e s i g n i f i c a n t . Of the 25 cases seen a f t e r d i a g n o s t i c conference, 13 d i d not proceed beyond f i v e i n t e r v i e w s a l t o g e t h e r a f t e r conference. Only 12 of 40 cases (30 per cent) continued to over f i v e i n t e r v i e w s , and f o u r cases (10 p e r cent) to over 10 i n t e r v i e w s a f t e r conference. In t h i s group of cases, i t might be s a i d t h a t treatment was g e n e r a l l y of a more s u p e r f i c i a l n a t u r e . 1 The heavy i n c i d e n c e of cases i n the groups r e f e r r e d because of " d i f f i c u l t y i n s o c i a l ad-justment" and " p e r s o n a l i t y r e a c t i o n s " suggested that minor adjustments were r e s p o n s i b l e f o r d i s c o n t i n u i n g treatment. These groups i n c l u d e d 7 of the 13 cases which proceeded to f i v e f u l l i n t e r v i e w s a f t e r the conference, 80 per cent were i n t h i s same category, a g a i n suggesting that the worker e i t h e r gave j u s t the i n f o r m a t i o n needed to take care of the problem, helped the c l i e n t accept c o n d i t i o n s which c o u l d not be changed*,- or made i t apparent that the c l i n i c was unable to h e l p the c l i e n t f u r t h e r . The f a c t that so many cases were c l o s e d i n a r e l a t i v e l y short time a f t e r the d i a g n o s t i c conference suggests t h a t p r e -conference treatment had been g i v e n more purpose and d i r e c t i o n . The a u t h o r i t y c a r r i e d by s e v e r a l p r o f e s s i o n s working as a team on each case, p l u s the thoroughness of t h e i r work, i s probably-a s t r o n g i n f l u e n c e i n the m o b i l i z a t i o n of a c l i e n t ' s e n e r g i e s around her problem. By the time a c l i e n t has d i s c u s s e d h e r problem w i t h a s o c i a l vrorker and has experienced something of treatment., she i s i n a good frame of mind to be impressed and i n f l u e n c e d by other f o r m a l i t i e s which are a p a r t of d i a g n o s i s . The p h y s i c a l examination i s necessary i n r e c o g n i z i n g cases i n which the d i s t u r b a n c e i s due to organic l e s i o n w i t h i n the 1. Length of treatment does not n e c e s s a r i l y mean that more i n t e n s i v e work was done s i n c e the r e a l gauge of depth of t r e a t -ment is_,the s t r e n g t h and c a p a c i t y of the c l i e n t . A strong B B m r f f e ?$i£ A&HFog?"™" l n J l i v e l y c e n t r a l nervous system. In some cases, the p h y s i c a l examination adds i n understanding behaviour and may d i s c l o s e d e f e c t s such as d e n t a l c a r i e s , b i r t h marks and other d i s f i g u r i n g f e a t u r e s which have a p o s s i b l e damaging p s y c h o l o g i c a l e f f e c t on.the c h i l d . The p s y c h o l o g i c a l examination i s concerned w i t h the e v a l u a t i o n of the c h i l d ' s innate a b i l i t i e s , e d u c a t i o n a l a c h i e v e -ments and s p e c i a l a p t i t u d e s . The p s y c h o l o g i s t i s able to p r e -d i c t w i t h i n c e r t a i n l i m i t s the maximum sch o o l achievement to be expected of a p a r t i c u l a r c h i l d , and the c h i l d ' s chanc:e f o r success i n some v o c a t i o n s . Having d i s c o v e r e d any s p e c i a l d i s -a b i l i t i e s , the p s y c h o l o g i s t can recommend s p e c i a l t u t o r i n g and treatment to overcome them. A program of r e m e d i a l r e a d i n g i s a v a i l a b l e f o r a l i m i t e d number of the c h i l d r e n found to be i n need of i t . In the p s y c h i a t r i c examination, the p s y c h i a t r i s t , because of h i s s p e c i a l t r a i n i n g , i s i n a p o s i t i o n t o view the i n t e r -:.  ".. r e l a t i o n s h i p of the p h y s i c a l and the mental. His s p e c i f i c -c o n t r i b u t i o n i n understanding the c h i l d i s the d i s c o v e r y and' e l u c i d a t i o n of the c h i l d ' s i n n e r motives, as these might b;e r e v e a l e d by h i s behaviour i n a c l i n i c i n t e r v i e w . The p s y c h i -a t r i s t may a l s o i n t e r v i e w both p a r e n t s , a l t h o u g h i n many i n -stances only the mother comes to c l i n i c w i t h the c h i l d . A f t e r completion of the f o u r procedures o u t l i n e d above, the c l i n i c a l " c o n f e r e n c e i s h e l d . On the b a s i s of the c o n s i d e r -ed judgement of the team, a d e c i s i o n i s made about b e g i n n i n g treatment. The type of work most r e l a t e d t o " a t t i t u d e therapy" i n c h i l d guidance development i s s t i l l a very important p a r t of -47-the s o c i a l worker's job. This i s shown by the fact that a mother i n a chil d ' s environment i s the person receiving most of the worker's attention. Mothers gained 58 per cent of the 426 interviews with the worker, as compared to 11 per cent f o r fathers. More interviews were recorded with mothers than with children, and t h e i r contact was often maintained with consist-ency beyond a t o t a l of ten interviews. This indicates that interviewing with mothers i s often a lengthy treatment process and of a r e l a t i v e l y complicated nature. The lack of p a r t i c i -pation of fathers i n treatment shown by these figures re-en-forces the general b e l i e f that i n this community fathers hold t h e i r spouses responsible f o r the rearing of t h e i r children. Only one father i n the 40 cases considered took part to the extent of six f u l l interviews. Only three proceeded to f i v e f u l l interviews. Table 5 Cases Showing Number of Interviews With Mothers of Child by Intelligence Quotient Intelligence Number of Interviews .quotient of c h i l d 0 L to 5 6 to 10 Over 10 Total Near G-enius 140 and over - — - - -Very Superior 120 to 139 - 2 1 2 5 Superior 110 to 119 - 2 2 - 4 Average 90 to 109 9 1 5 15 Low Average 80 to 89 - 6 1 1 8 Below Average 70 to 79 - 5 1 1 7 Below 70 - - - 1 • 1 Total 0 24 6 10 40 -48 -Table 6 Cases Showing Number of Interviews With the Child by Intelligence Quotient Intelligence quotient of c h i l d \ Number of Interviews Near Genius 140 and over Very Superior 120 to 139 Superior 110 to 119 Average 90 to 109 Low Average 80 to 89 Below Average 70 to 79 Below 70 0 1 to 5 Total 6 to 10 9 5 1 2' 2¥ Over 10 J Total 5 3 17 9 3 3 ~5b~ The Intelligence of a c h i l d was a determining fa c t o r i n the amount of interviewing done. Children of average i n t e l l i -gence and better were interviewed more often than those of less than average i n t e l l i g e n c e . On the other hand, the parents of an average or les s than average c h i l d received more of the worker's time. The figures suggest that, with the c h i l d of less than average i n t e l l i g e n c e , the helpfulness of a worker i s lim i t e d , and i n these cases the worker could well devote more time to work with the parent. •K The amount of long-term interviewing done i n the home was greater than that carried on within the c l i n i c . While workers make a practice of paying at least one c a l l to the home i n order to see the patent within h i s normal environment, "this i s -49-usually not extended'to the degree that i s evident i n working with mothers at the c l i n i c . It may be that physical f a c i l i t i e s , at the c l i n i c , which are recognized as .'delimit ing, had . some i n -fluence on the situation. Table 7 Interviews with Mother Held at C l i n i c , Home and by Telephone Means of Number of Interviews Over Total number contact 1 2 • 3 4 5 6 ' 7 8 9 10 10 Total Interviews C l i n i c 6 9 6 2' 1 1 2 - 2 1 - 3D 103 Home 8 5 2 2 - 1 3 2 - 1 3 27 120 Telephone 10 2 2 1 15 24 Total . 24 ±6 10 5 1 2 5 2 2 2 3' 72 Total number interviews 24 32 30 20 5: 12 35 16 18 20 35 247 The Personality of the Mother The number of interviews with a mother at the Vancouver Child Guidance C l i n i c i n 1950 was found to' be related to the kind of person the mother was. In any sort of psychological treatment!, time i s required f o r the person to benefit maximally. In case work treatment, as i n other kinds of therapeutic t r e a t -ment, time i s required' by •<the mother before..she i s able to bene-f i t from the case work relat i o n s h i p and the worker's s k i l l and knowledge. I f the mother i s an adequatte, secure and f a i r l y well-adjusted person, she w i l l be able to benefit from the re-lati o n s h i p and use i t as a growth experience without f e e l i n g too threatened by the r e a l i z a t i o n that some personal change i n a t t i -tude w i l l be required i f the d i f f i c u l t y she i s having with her c h i l d . i s to be cleared up. With anyone, the r e a l i z a t i o n that a change i s necessary for better functioning i s threatening. It -50-Table 8 C l a s s i f i c a t i o n of Mothers by Maturity Rating i n Relation to Interviews Received Number of Interviews Personality of Mot her Per Cent 1 11 111 IV Total One 1 2 - 7 10 25 2 to 5 6 5 5 3 - 14 35 6 to 10 4 • - 2 - 6 15 11 to 15 4 3 1 18 Over 15 — 1 2 — 3 7 Total 15 .11 7 7 . 40 100 i s because of t h i s threat to the mother's ego that i t i s necess-ary that she possess c e r t a i n personality strengths before the case work help offered can be accepted by her. In analyzing the 40 case records used i n t h i s study, the mothers can be described:by using a f o u r - f o l d c l a s s i f i c a t i o n system. Group 1 — " b e t t e r than average";—on the whole, the mother was found to be mature, secure, adequate;•possessed a basic f e e l i n g of worth, self-assurance and acceptance; was able to r e l a t e well to others. Mothers:in t h i s group were able to continue with the c l i n i c contact u n t i l the o r i g i n a l d i f f i c u l t y was resolved wholly or i n part. Group 11—"average"—the mother was f a i r l y mature, secure, and adequate; had a f a i r degree of self-assurance, f e e l i n g of worth, and acceptance; was able to relate.only f a i r l y w e l l . Mothers i n t h i s group were what might be c a l l e d the "average" mothers, and were able to benefit con-siderably from case work help, but not as much as the mothers i n the former group. The next group, Group 111—"less than average"—represented -51-mothers who were immature, insecure, inadequate; lacked feelings of self-assurance, worth, acceptance; had l i t t l e a b i l i t y to re-late to others. These mothers lacked the ego strengths necess-ary to benefit much from case work treatment. This l a t t e r sort of mother usually continued contact with the c l i n i c as long as the interviews focussed on a discussion of the c h i l d and his problem, but was unable to discuss her own part i n the contribu-t i o n of the c h i l d ' s problem. When t h i s kind of mother suspected that she had contributed to the problem, she was often l i k e l y to withdraw from c l i n i c contact at t h i s point. A great deal of support was necessary f o r t h i s kind of mother. Perhaps helping; her to maintain her present way of adjustement to her s i t u a t i o n was a l l that could be reasonably hoped for. Group IV—"incom-plete i n f o r m a t i o n " — i s the group i n which a l l the mothers were seen once; there was i n s u f f i c i e n t information to c l a s s i f y them on the Maturity Rating Scale. Of the 26 mothers (65 per cent) i n Groups 1 and 11, 12 (46 per cent) of them continued to more than f i v e interviews. Of these, 8 mothers (30 per cent) had over 10 interviews each. This i s compared to the 14 (35 per cent) mothers i n Groups 111 and IV, of whom only, 4 (28 per cent) had more than f i v e i n t e r -views. To these l a t t e r two groups—Group 111 and IV—belong the 7 mothers out of the 10 who had only one interview each. Success of case work treatment during the year 1950 at the Vancouver Child Guidance C l i n i c with mothers of pre-school children was dependent upon the personality of the mother. The pain of s e l f - r e v e l a t i o n can be borne only slowly and as the mother becomes secure i n the r e l a t i o n s h i p . There i s a need for -52 -eraotional change i n her before there can be a change of attitude or behaviour. An emotionally supportive rel a t i o n s h i p i s usually necessary, p a r t i c u l a r l y f o r i n f a n t i l e , n a r c i s s i s t i c p e r s o n a l i t i e s who need to be allowed" to become dependent f o r a time or i n t e r -mittently. Sometimes a worker cannot treat the mother at a l l , or at best i n c i d e n t a l l y ; sometimes she sees herself only as a means to enable the c h i l d to receive treatment. Sometimes a mother i s too i n f a n t i l e to do anything for h e r s e l f or make ef-fect i v e e f f o r t s to change. The very i n f a n t i l e mother who does Table 9 Status of Case at Closing by Adequacy Rating of Mother Personality . Status at Closing of Mother Considerable Improvement Slight Improvement Discontinued a f t e r Intake Total Per Cent Group 1 12 3 - 15 38 Group 11 . . 5 4 2 11 28 Group 111 3 4 - 7 17 Group IV - - 7 7 17 Total 20. 11 9 40 100 also mother -feels able to carry on without further c l i n i c contact. Slight Improvement i n ch i l d ' s behaviour; mother unable to benefit further from service offered by c l i n i c , usually because she f e l t too threatened by the impli-cations involved i n resolving the problem. Discontinued After Intake Interview because the service offered was not the kind the mother was looking for, or she had come to the c l i n i c i n a moment of weakness and no longer thought she needed to be concerned. " not assume f u l l r e s p o n s i b i l i t y f o r the c h i l d because she has a pattern of behaviour which depends on the d i r e c t i o n of others requires inexhaustible patience. The i n f a n t i l e mother must be helped to rearrange or redirect a f f e c t i o n . This kind of mother may get enough reassurance through the rela t i o n s h i p to assume - 5 3 -more r e s p o n s i b i l i t y . But g e n e r a l l y , treatment must be sustained 1 1 l o n g enough so that the c h i l d , a l s o c o n c u r r e n t l y i n treatment f o r h i m s e l f , has developed enough to go on i n s c h o o l and use other c o n s t r u c t i v e i n f l u e n c e s more or l e s s "under h i s own steam". In such cases, i t i s p a r t i c u l a r l y important to e n l i s t a c t i v e p a r t i c i p a t i o n by the f a t h e r . A mother^who cannot accept h e r p a r t i n the c h i l d ' s problem o f t e n argues that the problem i s due t o d i s e a s e or i n t e l l e c t u a l l i m i t a t i o n and she w i l l withdraw when she has found out what the I.Q. of h e r c h i l d i s . I f the mother, because of h e r own p e r s o n a l i t y , withdraws from treatment a f t e r one or two i n t e r -views, she w i l l not have experienced the h e l p t h a t can accrue from a p o s i t i v e w o r k e r - c l i e n t r e l a t i o n s h i p and the h e l p o f f e r e d by the worker. R e s i s t a n c e to treatment i s expressed i n many ways. The mother may p r o t e s t that the c h i l d i s much b e t t e r , as a way of making i t unnecessary f o r him to come i n any l o n g e r . She may a c t u a l l y r e s i s t s i g n s of improved adjustment i n the c h i l d . There are v e r y p r a c t i c a l reasons why i t i s hard f o r a mother not only to b r i n g a c h i l d i n , but a l s o to come i n h e r s e l f . In the be-g i n n i n g , a mother has to overcome h e r r e s i s t a n c e to treatment, her s u s p i c i o u s f e e l i n g s f o r the worker, and her doubts t h a t she can be h e l p e d w i t h the problem. Coming f o r treatment may arouse great a n x i e t y , e s p e c i a l l y i f the mother has s t r o n g defences i n some area, such as i n a b i l i t y to t a l k about h e r p a s t . Again, i f she withdraws a f t e r the i n i t i a l i n t e r v i e w or two, she w i l l be unable to overcome such f e e l i n g s . In p r a c t i c a l l y a l l success-f u l cases there i s an •honest q u e s t i o n i n g at times by the mother - 5 4 -of her own r o l e , followed by active enlistment and s e l f - i n v o l v e -ment i n treatment. In the closing summaries of the 40 cases studied, the workers recorded that there had been considerable improvement i n 20 cases. Of these 20 cases, 12 (60 per cent) were those i n which the mother was c l a s s i f i e d as "better than average". In the group "better than average", there were 15 mothers; 12 of these (80 per cent) showed considerable improvement as a result of case work treatment. Forty-five per cent of the "average" mothers and 42 per cent of the "less than average" mothers showed t h i s same improvement. It appears evident that, of the mothers being considered here, the ones most able to benefit from case work services as i t i s conceived and practiced at the Vancouver Child Guidance C l i n i c i n 1950 are those who are ade-quate and rather well-adjusted people. Conversely, the ones least able to benefit are the mothers who have personality d i f -f i c u l t i e s of t h e i r own which prevent them from continuing t h e i r contact with the c l i n i c . The methods of giving p r a c t i c a l services accompanied by case work help and manipulation of the environment are import-ant ones for s o c i a l work. However, i n t h i s study only methods that are encountered i n the face-to-face interview are under consideration—direct, treatment methods only are included i n the study. By "direct treatment" i s meant series of interviews carried on with the purpose of inducing or r e - i n f o r c i n g attitudes fav-ourable to maintenance of emotional equilibrium, of making con-structive decisions, and to growth or change. The term also - 5 5 -i n c l u d e s p s y c h o l o g i c a l support, always a l a r g e f a c t o r i n case work methods of adjustment. In a l l case work methods, i t i s assumed t h a t the c l i e n t i s helped to be more keenly aware of the s i t u a t i o n and of h e r s e l f i n r e l a t i o n to the s i t u a t i o n . The most common e x p r e s s i o n of d i r e c t i n t e r v i e w i n g t r e a t -ment i s g i v i n g i n f o r m a t i o n . T h i s method i s intended t o he l p a c l i e n t i n a r a t i o n a l way to s o r t out the i s s u e s i n h e r s i t u -a t i o n to c l a r i f y h er problem and her c o n f l i c t s w i t h r e a l i t y , to d i s c u s s the f e a s i b i l i t y of v a r i o u s courses of a c t i o n , and to f r e e the c l i e n t r e a l i s t i c a l l y , to assume the r e s p o n s i b i l i t y of making a ch o i c e . The main technique i s , perhaps, that of c l a r i f i c a t i o n of the problem and f e e l i n g s and a t t i t u d e s toward i t . G i v i n g i n f o r m a t i o n though " e d u c a t i o n a l " i s not a p u r e l y i n t e l l -e c t u a l e x e r c i s e s i n c e a l l l e a r n i n g i s e m o t i o n a l l y motivated. The focus of g i v i n g i n f o r m a t i o m a n d c l a r i f i c a t i o n i s the immediate s o c i a l s i t u a t i o n which must be r e s o l v e d— r i t s aim i s to e n l i s t the c o - o p e r a t i o n of the conscious ego i n d e a l i n g w i t h s o c i a l problems and making s o c i a l a d a p t a t i o n s . The case worker makes c a u t i o u s use of i n t e r p r e t a t i o n , of e i t h e r s o c i a l or p e r s o n a l f a c t o r s and t h e i r i n t e r a c t i o n , u s u a l l employing techniques of c l a r i f i c a t i o n , and s u p p o r t i n g the ego w i t h i n vthe r e l a t i o n s h i p , w i t h l i t t l e p e n e t r a t i o n of defences u n l e s s n e g a t i v e and u n u s u a l l y d i f f i c u l t phases of r e s i s t a n c e occur. Case workers use knowledge of p s y c h o l o g i c a l determinants i n p e r s o n a l i t y s t r u c t u r e to s t i m u l a t e the c l i e n t to make more c r e a t i v e c h o i c e s : to h e l p h e r assume s o c i a l r e s p o n s i b i l i t i e s f o r h e r s e l f , h e r f a m i l y , h e r community; to bear s t r a i n s and - 5 6 -p r e s s u r e s with, l e s s wear and t e a r ; to modify habit's of s e l f -blame and f e e l i n g s of inadequacy; and, because of u nderstanding and support, to use l e s s a g g r e s s i o n , a n x i e t y , r i g i d i t y and p r o-j e c t i o n i n her s o c i a l r e l a t i o n s h i p s i n a r e a l , economic and c u l t u r a l environment. The method of conducting an i n t e r v i e w w i l l be i n f l u e n c e d to a c o n s i d e r a b l e extent by the purpose of that i n t e r v i e w . Some in t e r v i e w s are d i r e c t e d p r i m a r i l y to o b t a i n i n g i n f o r m a t i o n , some p r i m a r i l y t o g i v i n g h e l p , but most i n v o l v e a combination of the two. The aim i s to o b t a i n knowledge of the problem to be s o l v e d and s u f f i c i e n t understanding of the person t r o u b l e d and of the s i t u a t i o n so that the problem can be s o l v e d e f f e c t i v e l y . Most of the case work treatment methods used are of a sup-p o r t i v e nature r a t h e r than of an i n t e r p r e t i v e or " i n s i g h t g a i n i n g " s o r t . T h i s seems to i n d i c a t e that many of the d i f f i -c u l t i e s of the c h i l d r e n brought to the c l i n i c are of such a nature that the mothers can do much t o r e s o l v e them by u s i n g i n f o r m a t i o n and suggestions that are given'when accompanied by p s y c h o l o g i c a l support and acceptance. The c l i e n t may-be n o t i c e -ably a f f e c t e d by the warmth and s i n c e r i t y of the worker's d e s i r e to help as w e l l as the a c t u a l demonstration of treatment methods d u r i n g the c o n t a c t . Thw worker demonstrates h i s treatment s k i l l s i n short-term i n t e r v i e w s as w e l l as i n those extending over many months. Even i n a s i n g l e i n t e r v i e w he i s o f t e n able to i n f l u e n c e the c l i e n t through the medium of h i s p e r s o n a l i t y and the conscious use of methods. G i v i n g i n f o r m a t i o n , p s y c h o l o g i c a l support, a i d i n g e x p r e s s i o n of f e e l i n g and a c c e p t i n g i t , are o f t e n a p p l i e d i n -57-Table.10 Frequency of Case Work'Interviewing Methods, Personality of Mother, Number of Interviews Case Work Frequency of Interviewing Method Total Methods Interviewing . N umber Per Cent Per Method 1 h 11 111 IV 1 11 111 IV Number . Cent Enc ouragemei tt to Talk 87 69 53 11 12 10 14 19 220 12 Moving with Client 79 75 56 4 10 11 15 7 214 12 Giving ,16 Inf ormatior L109 137 70 9 14 21 19 325 18 Guiding Discussion 59 54 29 6 8 8 8 11 148 8 Motivating 53 82 49 5 7 12 13 9 189 10 Aiding Expre s. of Feeling 70 52 20 3 9 8 6 6 145 8 Accepting EJ -58 pres.of Fee ling 43 19 3 8 6 5 6 123 7 Supporting 95 84 27 3 13 13 7 6- 209 11 C l a r i f y i n g 37 20 19 2 5 3 5 4 78 4 Focussing 20 8 1 2 3 1 1 4- 31 2 Rechannellir gl7 9 7 2 2 1 2 4 35 2 Interpreting 61 30 19 2. 8 5 5 4 112' • 5 Setting Limits 4 7 4 1 1 1 1 4 17 1 Total Frequencies 749 670 373 54 100 100 100 100 1846 100 Number of Interviews 106 76 58 7 43 31 23 3 247 100 Number of Mothers 15 11 7 7 38 28 17 17 40 100 short contacts. Over longer periods of time, and i n r e l a t i o n to the mother's personality strengths, the worker undertakes to influence the c l i e n t on more fundamental emotional l e v e l s while keeping i n mind diagnosis and aims of treatment. Of the case work methods used with the 40 mothers under consideration, approximately 90 per cent were of a supportive, c l a r i f y i n g kind. The cases carried by s o c i a l workers on an intensive'basis -58- , amounted to 10 per cent of the t o t a l number of forty cases. About h a l f of these made use of insight."'' From an analysis of the recording of the case work carried out with the 4-0 mothers, there i s d e f i n i t e i n d i c a t i o n that the personality of the mother affects the kind of case work methods that can e f f e c t i v e l y be employed. Also, i t i s imperative, i f the mother i s to continue to come to the c l i n i c , that the cor-rect methods be used. This requires an early diagnosis of the mother's strengths andweaknesses by the worker. For example, the "less than average" mothers need more encouragement (13 per cent) to continue treatment, than the "better than average" mothers (7 per cent). These same mothers also seem to require more information than the other group. This points up the gen-e r a l l y accepted b e l i e f , that the rather inadequate person wishes to solve the problem without much personal p a r t i c i p a t i o n i n the solution. Rather, they want the worker to "make over" the c h i l d ; want to be t o l d what to do to solve the d i f f i c u l t y . At the same time, t h i s group of mothers seem to benefit very l i t t l e from the information that they do receive. Mothers i n Group 1 ("better than average") seem readier or more able to accept interpretation (54 per cent) than were the mothers.in Group 11 (27 per cent) and Group 111 (8 per cent). The technique c a l l e d "aiding the expression of f e e l i n g " was employed most often with Group 1 (48 per cent) as was "accept-ing the expression of f e e l i n g " (46 per cent); compared with Group 11 (36 per cent and 34 per cent respectively); Group 111 (14 per cent and 15 per cent r e s p e c t i v e l y ) . This l a t t e r f i nding seems to agree with the theory which holds that the "better than 1. Insight case work requires most s k i l l and depends upon a process of transference, i n which the worker i s i d e n t i f i e d with someone i n the c l i e n t ' s personal l i f e . Interpreting, rechannell-ing and c l a r i f y i n g are most commonly used i n t h i s type of work. -59-average" person has the " s t r e n g t h of c h a r a c t e r " which permits him to share or v e n t i l a t e h e r f e e l i n g s and a t t i t u d e s . How-ever, w i t h h e r as w e l l as w i t h a person w i t h l e s s s t r e n g t h of c h a r a c t e r , p s y c h o l o g i c a l support and acceptance from the worker are necessary. F o c u s s i n g , a method which depends upon a good worker-c l i e n t r e l a t i o n s h i p , was used most f r e q u e n t l y w i t h the " b e t t e r than average" mothers (65 per c e n t ) ; Group 11 (26 per c e n t ) ; Group 111 (3 per c e n t ) ; Group IV (6 per c e n t ) . R e c h a n n e l l i n g , the method i n treatment which has as i t s aim h e l p i n g the c l i e n t to be as aware as p o s s i b l e of the ways i n which she i s r e a c t i n g t o r e a l i t y f a c t o r s , and c o n t r i b u t i n g t o the problem, and to h e l p h e r to r e d i r e c t these impulses t o more ac c e p t a b l e ways of behaving, was dependent upon the per-s o n a l i t y of the mother and q u a l i t y of the w o r k e r - c l i e n t r e l a -t i o n s h i p . With the " b e t t e r than average" mothers, t h i s t e c h -nique was used 49 per cent of the t o t a l number of times; w i t h Group 11, i t v/as used 26 per cent of the time; w i t h Group 111, 20 per cent. Phases of Treatment In s o c i a l case work, the worker i s able to c o n t r i b u t e d i r -e c t l y to the movement of a c l i e n t through the treatment pro-cess. The worker makes h i s c o n t r i b u t i o n by d e l i b e r a t e and t h o u g h t f u l a p p l i c a t i o n i n r e l a t i o n t o the c l i e n t ' s needs. In the present study, treatment seemed to f a l l i n t o t h r e e d e f i n -able stages w i t h i n treatment. The worker's methods were seen to be r e l a t e d to the "movement" the mother was making i n r e -s o l v i n g h e r d i f f i c u l t i e s . The stages may be described: i n the - 6 0 -g e n e r a l order of appearance d u r i n g treatment as the d e f i n i t i o n of the h e l p i n g s i t u a t i o n ; working through emotional c o n f l i c t , acceptance of s e l f i n r e l a t i o n . t o the problem, c l a r i f i c a t i o n of fundamental i s s u e s ; i n i t i a t i o n of p o s i t i v e a c t i o n , i n s i g h t , e x p r e s s i o n of p e r s o n a l adequacy or s o c i a l impulse. However, these stages are not c l e a r cut; the methods used are not ex-c l u s i v e to any one phase of treatment. The d e f i n i t i o n of the h e l p i n g s i t u a t i o n u s u a l l y takes on d e f i n i t e form. The c l i e n t expresses the d e s i r e f o r h e l p i n her own words and the worker responds by i n d i c a t i n g a d e s i r e to h e l p . The c l i e n t i s encouraged to say what k i n d of s e r v i c e she i s e x p e c t i n g from the c l i n i c , and the worker d i s c u s s e s t h i s i n r e l a t i o n to the h e l p t h a t i s a c t u a l l y a v a i l a b l e . ^ These steps h e l p to m o b i l i z e the energy of the c l i e n t i n a s p e c i f i c a rea, and are r e - e n f o r c e d by an e a r l y demonstration of help by the worker, as f o r example i n g i v i n g i n f o r m a t i o n to meet an immediate need, or a i d i n g and a c c e p t i n g the c l i e n t ' s e x p r e s s i o n of f e e l i n g . Reassurance concerning the c o n f i d e n t i a l i t y of the s i t u a t i o n i s c a r e f u l l y made. The degree to which the c l i e n t moves i n t o the h e l p i n g s i t u a t i o n , accepts i t and agrees to make use of i t , a l s o depends on the f o r m a t i o n of a r e l a t i o n -ship of t r u s t and confidence i n the worker. By the time i n -f o r m a t i o n has been gathered f o r the d i a g n o s t i c conference and e a r l y demonstration of the worker's treatment s k i l l s has,been made, the c l i e n t i s more comfortable i n the s i t u a t i o n and i s f r e e to move i n t o the next stage. The examining process at the c l i n i c and the worker's d i s c u s s i o n of d i a g n o s i s h e l p s to give t h i s movement more d i r e c t i o n . -61-For t h i s phase of treatment, 43 per cent of the treatment methods were used. Of these methods, the mothers i n Group 1 required 37 per cent; Group 11, 4-3 per cent; Group 111, 49 per cent; and Group IV, 46 per cent of the t o t a l f o r t h e i r group. Of the t o t a l number of techniques used with the 40 mothers,, 43 per cent were used f o r t h i s phase of treatment. The next area of treatment consisted of some combination of the elements c a l l e d acceptance of s e l f i n r e l a t i o n to the problem, working through emotional c o n f l i c t , and c l a r i f i c a t i o n  of fundamental issues. These elements could appear i n d i f f e r -ent order and as an expression of d i f f e r e n t needs on the part of the mother. Treatment methods i n t h i s phase usually were predominantly those of psychological support and motivation to p a r t i c i p a t e and develop as an i n d i v i d u a l . Also of c l a r i f y i n g broad issues, and past d i f f i c u l t i e s i n r e l a t i o n to the present (focussing). This stage was usually cl o s e l y i n t e r - r e l a t e d with the working through of emotional c o n f l i c t . The worker both accepted the c l i e n t ' s expression of f e e l -ing and rechannelled her impulses to other areas.. In r e l a t i o n to the worker's acceptance of expression of f e e l i n g , p a r t i -c u l a r l y negative f e e l i n g , the c l i e n t might often gain insight into the meaning of her rela t i o n s h i p to her s i t u a t i o n . This phase of treatment required 52 per cent of the case work tech-niques employed. Of the methods used i n each group f o r t h i s phase of treatment, mothers i n Group 1 used 55 per cent of them; Group 11, 52 per cent; Group 111, 46 per cent; Group IV, 50 per cent. The t h i r d general phase of treatment—insight, growth, -62-Table 11 Stages of D i f f e r e n t i a l Case Work Treatment: In Relation to Frequency of Case Work Techniques, Maturity of Mothers, and Number of Interviews. Frequency of Interviewing Methods T tal Methods Stage of N umber Per Cent Ember Per Treatment 1 11 111 IV 1 11 111 IV Cent 1.Definition of Help ing Situat ion Enc ouragement to t a l k Moving with c l i e n t Giving information Setting l i m i t s 87 79 109 4 69 775 137 7 53 56 70 4 11 ^ . 9 2 12'. 10 14 1 10 11 21 1 14 15 19 1 19 7 16 4 220 214 325 17 12 12 18 1 .2. Total 279 288 183 26 37 43 49 46 776 43 2 . C l a r i f i c a t i o n of Fundamental Is sue s Guiding discussion 59 54 29 6 8 8 8 11 148 8 Motivating Aiding Expres-sion of Feeling Accepting Expres sion of leeling 53 70 58 82 52 43 49 20 19 5 3 3 7 9 8 12 8 6 13 6 5 9 6 6 189 145 123 10 8 7 Support ing 95 84 27 3 13 13 7 6 209 11 C l a r i f y i n g 37 20 19 2 5 3 5 4 78 4 Focussing . 20 8 1 2 3 1 1 4 31 2 Re c hanne 11 ing 17 9 7 2 2 1 2 4 35 2 Total 409 352 171 26 55 52 46 50 958 52 3. Insight, i n i t i -ation of posi-tive action Interpreting 61 30 19 2 8 5 5 4 112 5 Total • 61 30 19 2 8 5 5 4 112 5 ( 1 ) C l a r i f i c a t i o n of fundamental issues, working through emotional c o n f l i c t , acceptance of s e l f i n r e l a t i o n to the problem. (2) I n i t i a t i o n of positive action, insight, expression of personal adequacy. - 6 3 -I n i t l a t i o n of pos i t i v e a c t i o n — o f t e n over-lapped the preceding one; the vrorker continued to give psychological support and encouragement. The c l i e n t expressed some confidence i n her capacities and adequacies. This expression was usually preceded by expressing and re-experiencing the past emotionally. The worker might interpret the c l i e n t ' s feelings or not, but i n any case, insight often followed. Often i n l i e u of interpreting f e e l i n g s , the worker's act of accepting the c l i e n t ' s expressed negative feelings was cl o s e l y linked with insight that might follow. Again, i t i s to be noted that the personality of the mothers affected t h e i r a b i l i t y to benefit from more intensive treatment. An important contributing factor, also related to the mother's character, was the length of treatment, that i s , the number of interviews held with each mother. The greatest number of mothers able to benefit from t h i s more intensive case work, were those who had over ten interviews each. Of the t o t a l number of case work methods used, 5 per cent were employed during this phase of treatment. The mothers i n Group 1 benefitted from interpretation, from which insight usually followed, to the extent of 54 per cent;:Group 11, 27 per cent; Group 111, 17 per cent; and Group IV, 2 per cent. In summary, a d e f i n i t e influence i n treatment i s the kind of person the mother i s . That i s , her personality determines whether, f i r s t , she can continue a f t e r the intake interview. Second, i f t h i s i s possible, whether she i s able to continue the contact long enough to benefit from the help the worker o f f e r s , and, consequently to modify some of her attitudes and methods of handling her environment (usually her c h i l d ) . -64 -L a s t l y , whether she has the strength of character or ego strengths to g a i n i n s i g h t from more i n t e n s i v e case work t r e a t -ment and as a r e s u l t f e e l more adequate and express more s e l f -confidence i n her c a p a c i t i e s . The movement from phase to phase i s , of course, accompanied by a deepening of the w o r k e r - c l i e n t r e l a t i o n s h i p . I t i s t h i s l a t t e r f a c t o r combined w i t h the mother's ego strengths, that•determine the l e v e l of case work treatment, that i s , the case work' treatment methods used. - 6 5 -Ghapter 4 . D i f f e r e n t i a l Case Work Treatment In the c l i n i c a l setting,, the worker's capacity to i n f l u -ence human behaviour i s formalized somewhat by the program b u i l t around diagnosis and treatmnnt. Although t h i s study shows that a large, part of treatment was on a short-term bas i s , the worker was able to give treatment through the medium of the i n -terview from the beginning of the contact. Treatment was given a d e f i n i t e orientation to fundamental factors by the diagnostic conference, and work with the c l i e n t s could then continue with greater i n t e n s i t y from that point. The vrorker's close atten-t i o n i n frequent interviews was seen as a d e f i n i t e influence i n mobilizing the e f f o r t of the c l i e n t toward solution of her problem. At the Child Guidance C l i n i c at Vancouver, the worker's e f f o r t s i h treatment are helped greatly by the c l i n i c team. One person takesithe basic r e s p o n s i b i l i t y f o r the c l i e n t , and he consults other team members f r e e l y . Through using t h i s team approach, the psychiatric case workers i n t h i s c l i n i c are able to take r e s p o n s i b i l i t y f o r a great many cases of support-ive treatment and an impressive number of cases requiring more intensive case work methods. The study involves a diagnosis.of the personality of the mothers and how t h i s affected the use of case work treatment methods. The rela t i o n s h i p was the medium through which the c l i e n t was enabled to enter into the treatment process. Some common elements of t h i s treatment process were (a) helping the c l i e n t to use the service offered, (b) c l a r i f i c a t i o n of r e a l i t y -66-f a c t o r s , and (c) changing negative f e e l i n g s and a t t i t u d e s i n t o p o s i t i v e and h e a l t h y ones. The main p s y c h o l o g i c a l aims were the p r e s e r v a t i o n of a t t i t u d e s of s e l f - c o n f i d e n c e through (a) encouragement, (b) reassurance, and (c) c l a r i f i c a t i o n of reasons f o r c e r t a i n p a t t e r n s of behaviour. Case work was designed t o b r i n g about some m o d i f i c a t i o n of. behaviour and a t t i t u d e s , and r e s t e d on a d i a g n o s i s of the t o t a l p e r s o n a l i t y . Ittseems important t o s t r e s s that the case work treatment methods used were overwhelmingly of a su p p o r t i v e n a t u r e — a sup-p o r t i n g of s t r e n g t h s . T h i s s u p p o r t i v e technique i n c l u d e d ree assurance, p e r m i s s i v e a t t i t u d e s t h a t r e l i e v e d g u i l t , and a pro-t e c t i v e r e l a t i o n s h i p . The understanding of the t r a n s f e r e n c e and the d i a g n o s i s i n t h i s method formed a b a s i s f o r the r e l a t i o n -s h i p . T h i s r e l a t i o n s h i p was used not so much to motivate change as i t was to support the c l i e n t ' s a c c e p t a b l e e x i s t i n g aims and to h e l p h e r r e s o l v e undue pressure which c o u l d c o n t r i b u t e to ar breakdown. T h i s technique was p a r t i c u l a r l y s u i t a b l e f o r c l i e n t s w i t h weak ego s t r u c t u r e s . These c l i e n t s i n c l u d e d i n f a n t i l e char-a c t e r s , i n s e c u r e people, dependent people and other k i n d s . These were mothers who were a l l w e l l enough to l i v e i n the com-munity and to p a r t i c i p a t e i n most aspects of adequate s o c i a l f u n c t i o n i n g . Although the treatment was r e c o g n i z e d as l i m i t e d , b e i n g designed p r i m a r i l y to m a i n t a i n present s t r e n g t h s , the r e s u l t s i n d i c a t e d t h a t p s y c h o l o g i c a l improvement o f t e n o c c u r r e d . Supportive case work was used sometimes because the chances of success i n i n t e n s i v e i n t e r p r e t i v e treatment would have been - - 6 7 -poor i n view of the long-standing nature of the c l i e n t ' s per-sonality d i f f i c u l t i e s . Sometimes t h i s method was used because the c l i e n t ' s relationships to people seemed to be on a tenuous basis: most of these mothers had suffered from severe depriva-t i o n i n t h e i r early l i v e s . For t h i s reason, workers f e l t that the outcome of interpretive case work would not be promising; workers therefore l i m i t e d themselves to a program of supportive treatment. ( As has been indicated repeatedly i n t h i s study, a f i r s t objective i n supportive treatment i s to improve the l e v e l of the c l i e n t ' s s o c i a l adjustment. The objection may be raised that helping the c l i e n t to make a better s o c i a l adjustment i s not an element peculiar to supportive treatment, but that i t i s an essential objective i n any kind of treatment. Although t h i s objection i s a v a l i d one, i t seems that there are differences i n the methods of. achieving the g o a l — t h a t the means of improving the s o c i a l adjustment depends on the general nature of the treatment p r i n c i p l e . As an ov e r - s i m p l i f i c a t i o n , perhaps i t can be said that, i n supportive treatment, e f f o r t s at improve-ment of the s o c i a l s i t u a t i o n must come f i r s t and must have the active p a r t i c i p a t i o n of the worker; i n inte r p r e t i v e treatment, the improvement of the s o c i a l s i t u a t i o n comes la s t and c a l l s f o r l i t t l e and perhaps no active p a r t i c i p a t i o n on the part of the worker. As the worker helps the c l i e n t to reduce her feelings of anxiety, the ego gains strength to handle immediate situations and the experience of more adequate functioning becomes i t s e l f a growth process. This was noted to be the case with the "less than average" mothers. Seven and one h a l f per " - 6 8 -cent of these mothers were able to show "considerable improve-ment" as a resu l t of case work treatment. As a result of t h i s study, a conviction i s gained that supportive treatment i s an excellent t o o l i n helping c l i e n t s . As a group, the majority of mothers, some with rather simple problems, some with severe disturbances, made adjustments ranging from s l i g h t improvement to very successful adjustments. Although supportive treatment distinguishes i t s e l f from insight treatment by the exclusion of interpretation as a main t o o l , some interpretation was found to be very valuable. Workers at the Child Guidance C l i n i c found, while they excluded attempts to interpret the dynamics of the unconscious, that they were successful i n interpreting connections within the mother's current l i f e s i t u a t i o n . This method was used i n about ten per cent of the cases studied. Case work designed to re-sult i n helping the c l i e n t gain insight was necessary to meet some of the problems of malfunctioning that were often found i n c l i e n t s . Insight was aimed at achieving a change i n the ego by developing the c l i e n t ' s insight into her d i f f i c u l t i e s and i n -creasing the a b i l i t y of the ego to deal with them through the emotional experience i n the transference s i t u a t i o n . The main d i f f i c u l t i e s with the method of insight centered' around the selection of appropriate c l i e n t s , the selection of the central problem to be brought under treatment, the develop-ment of interpretive techniques that could a i d the c l i e n t i n gaining understanding of feelings and motivations conditioning her defensive patterns and the kind of environmental a c t i v i t y that could be appropriately introduced. -69-With this method, the transferencesrelationship was used to help the c l i e n t understand her i r r a t i o n a l impulses, how they arose i n the past and how the present s i t u a t i o n d i f f e r e d , so that she could modify her behaviour accordingly. The trans-ference was controlled as to i n t e n s i t y , so as not to i n t e r f e r e with the c l i e n t ' s judgement and co-operation. The transference was sometimes interpreted when the c l i e n t ' s negative or p o s i t i v e attitudes toward the worker were used as resistance to going on toward further insight or toward a greater maturity i n her r e a l l i f e s i t u a t i o n . If s o c i a l agencies r e s t r i c t the type of problem and res-t r i c t the l e v e l of the c o n f l i c t which w i l l be treated by the methods discussed i n t h i s study, valuable new knowledge and techniques may be prevented from becoming.known. Restrictions set up i n advance "because cert a i n a c t i v i t y does not seem ap-propriate for case work" w i l l prevent progress and experimen-t a t i o n . What may have been accepted as true t r a d i t i o n a l l y , • may not be true forever i n the l i g h t of new knowledge. What workers can do w i l l , of course, be influenced by the kind of t r a i n i n g prescribed by schools of s o c i a l work fo r the worker's equipment fo r p r a c t i c e . Perhaps the implication of t h i s study for t r a i n i n g of case workers could be mentioned. It appears' that a more dynamic t r a i n i n g i n p s y c h i a t r i c concepts i s i n d i -cated, based on the assumption that the case worker w i l l need i t f o r a more dire c t r e s p o n s i b i l i t y i n t r e a t i n g psychological problems found i n some c l i e n t s that come to a c l i n i c for help. In the present two-year t r a i n i n g period, the student i s well i n i t i a t e d into ego-supportive case work and the related tech--70-niques. However, t o e s t a b l i s h a p r o f i c i e n c y i n treatment aimed at d e v e l o p i n g i n s i g h t , f u r t h e r t r a i n i n g seems i n d i c a t e d . Re-c o g n i z i n g t h a t f u r t h e r graduate work i s i n d i c a t e d , some schools are o f f e r i n g a t h i r d year of study f o l l o w i n g a minimum of two years' experience a f t e r the master's degree. The f u t u r e i n case work looks p r o m i s i n g . Methods have developed out of past experiences and the g a i n i n g of new know-ledge. T r a d i t i o n a l t r a i n i n g has a l r e a d y g i v e n workers a back-ground and p a r t i a l t r a i n i n g i n techniques that make f u r t h e r t r a i n i n g a l o g i c a l e x t e n t i o n of the present s i t u a t i o n . Increased understanding of the problems f o r which workers accept respon-s i b i l i t y n e c e s s i t a t e s r e v i s i o n s and e x t e n s i o n of methods. 1 Concrete case work treatment methods, based on understanding of the c l i e n t ' s p e r s o n a l i t y are necessary i n order to do an adequate job. ~. L u c i l l e Austin, "Trends i n D i f f e r e n t i a l Treatment i n Social Casework", Journal of S o c i a l Casework. June 1948. Books BIBLIOGRAPHY Freud, Anna, " I n d i c a t i o n s f o r C h i l d A n a l y s i s " , The P s y c h o a n a l y t i c Study of the C h i l d , New York, 1945, V o l . 1. . Freud, Anna, " I n t r o d u c t i o n t o the Technic of C h i l d A n a l y s i s , New York, ..Nervous and Mental Disease P u b l i s h i n g Co., 1928. G a r r e t t , Annette, I n t e r v i e w i n g , I t s P r i n c i p l e s and Methods, Family S e r v i c e A s s o c i a t i o n of America, New York, N.Y.,1942. Hamilton, Gordon, Psychotherapy i n C h i l d Guidance, Columbia U n i v e r s i t y P r e s s , New York, N.Y., 1947. H o l l i s , F l o r e n c e , S o c i a l Case Work i n P r a c t i c e , Family Welfare A s s o c i a t i o n of America, New York, N.Y., 1939-Kanner, Leo, C h i l d P s y c h i a t r y , S p r i n g f i e l d , 111., C C . Thomas, 1935. Robinson, V i r g i n i a , A Changing Psychology 'in S o c i a l Work, Chapel H i l l , N.C., U n i v e r s i t y of North C a r o l i n a Press,1930. W i t m e r H e l e n Le l a n d , P s y c h i a t r i c Interviews w i t h C h i l d r e n , New York, The Commonwealth Fund, 1946. P e r i o d i c a l s A l l e n , F r e d e r i c k H., " C r e a t i o n and Handling of R e s i s t a n c e In C l i n i c a l P r a c t i c e " , American J o u r n a l of O r t h o p s y c h i a t r y , 2:268, J u l y 1 9 3 2 . . . . . . •A u s t i n , L u c i l l e , "Trends i n D i f f e r e n t i a l Treatment i n S o c i a l Casework", J o u r n a l of S o c i a l Casework, June 1948. Burlingham, Dorothy .T., " C h i l d A n a l y s i s and the Mother", Psycho-a n a l y t i c Quarterly,-4:75-76, January 1935* Conn, Jacob H., "Treatment of F e a r f u l C h i l d r e n " , American  J o u r n a l of O r t h o p s y c h i a t r y , 11:744. . . . Dawley, Almena, " I n t e r - R e l a t e d Movement of Parent and C h i l d i n Therapy w i t h C h i l d r e n " , American J o u r n a l of O r t h o p s y c h i a t r y , 9:748-754. Glassman, L i l l i a n , "Is D u l l Normal I n t e l l i g e n c e a C o n t r a - i n d i c a -t i o n f o r Psychotherapy?", Smith C o l l e g e S t u d i e s i n S o c i a l Work, 13:275-298, March 19WT" Levy, David, " A t t i t u d e Therapy", American J o u r n a l of Ortho-p s y c h i a t r y , 7:103-113, January 1937. Levy, David, "Freud and C h i l d P s y c h i a t r y " , American J o u r n a l of  Or t h o p s y c h i a t r y , 10:861-862, October 1940. Meyer, A d o l f , "The Role of Mental F a c t o r s i n P s y c h i a t r y " , Ameri-can J o u r n a l of I n s a n i t y , 65:43, J u l y 1908. Meyer, A d o l f , " T h i r t y - F i v e Years of P s y c h i a t r y i n the U n i t e d S t a t e s and Our Present Out-look", American J o u r n a l of P s y c h i a t r y , 8:9, J u l y 1928. S c h i l d e r , P a u l , " P e r s o n a l i t y i n the L i g h t of P s y c h o a n a l y s i s " , P s y c h o a n a l y t i c Review, 22:41, January 1935. S y l v e s t e r , Emmy, "Symposium: Psychotherapy of C h i l d r e n " , American J o u r n a l of O r t h o p s y c h i a t r y , 15:30, January 1945. Other S t u d i e s Glover, G e o f f r e y , "Case Work I n t e r v i e w i n g Methods i n a C h i l d Guidance S e t t i n g " , M.S.W. T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1951. -

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0106799/manifest

Comment

Related Items