Journal of Family Therapy (1979) 1: 183-192

Family therapy as a setting for other treatment modalities

Dora BlackX

After many years of experiencing the confusion a chameleon must feel on landing on a patchwork quilt, as I attempted to integrate the various current theories about the aetiology of childhood psychiatric disorders, I found myself working empirically, as a family therapist, using all the patterns of the quilt in what I hope is an integrated way rather than being confused by them.

My style of family therapy derived from the attempt to integrate a biological approach derived from medical training; a psychoanalytic approach derived from my analysis and the theories and therapies used in my early child guidance days. Added to these were the theories of Bowlby (1969, 1972) on attachment and loss, Caplan (1961) on crisis and Winnicott (1971) on minimal intervention as well as learning theory and behaviour therapy, and the theories of the group analysts and family therapists especially Skynner (1976), Minuchin (1974) and Haley (1976).

Within the preferred mode of conjoint family meetings I have found myself using one or more therapies normally thought of as alternatives to family therapy ; especially behaviour therapy, individual therapy and drug therapy, whilst maintaining a family-centred approach and working within a theoretical framework which views a symptomatic child as the presenting symptom of family disturbance. A family will be offered a contract of six to ten family meetings at about two to four weekly intervals which will focus in the usual way on patterns of communication, sub- systems, coalitions, attitudes brought from the parents’ own families of origin etc. The emphasis is on change and any technique which will facilitate change is used, but used in the family contest. For example, if everyone in a family agrees that Johnny’s temper tantrums result from frustration; that mother is unreasonably frustrating him because her

* Edgware General Hospital and Child Guidance Centre, Edgware, Middx. and Hospital for Sick Children, Great Ormond Street, London WCl.

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0163-4445/79/0201S3+10 $02.00/0 0 1979 The Association for Family Therapy

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child-rearing theories are based on an upbringing more appropriate to an earlier era, and that Johnny is specially vulnerable because of his irritable temperament, then a behavioural programme may reward mother for not nagging as well as Johnny for not having a temper when she does nag. The reward for mother might come from father, or from a less involved sibling, thus ensuring that all the family see it as their problem, and participate in the treatment.

This approach is different from using family therapy plus one of the other therapies side by side for it involves the adaptation of the other therapies to take place in a family context. Everyone in the family will have a task-a sibling’s task may be to remind mother to administer a drug which will help Jane to concentrate for longer; and he may himself have a behavioural programme to help him to keep his room tidy. It allows the use of family therapy techniques such as sculpting, geneograms, para- doxical injunctions, task setting. Perhaps the most difficult technique to adapt is individual therapy.

Case no. 1

Brenda 11 years. Referred by parents for advice about schooling.

Family Father 54

Mother 41

Kevin 139

History

About to retire from Army. A placid, quiet, supportive man. Works part-time, devoted to helping lame ducks. A devout, somewhat mystical person, sensitive, caring and very patient. A gentle, unassertive boy, like his father. Academically able. He had an unsuccessful boarding school placement when Brenda was at her worst at home.

Brenda came into the family as a foster child at five months. Her biological mother had seven other children and had clearly maltreated her. She was covered with bruises, burns and infections, was severely retarded and very disturbed. She was eventually adopted and came under the care of a child psychiatrist at two and a half years because of severe behaviour problems-temper tantrums, disobedience, soiling and smearing and retardation. No clear diagnosis was made but it was thought Brenda was probably brain-damaged and possibly autistic. Her adoptive mother was exhausted by her

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but responded well to social work support and counselling. Brenda began to talk at four years. She had many rituals and obsessions but was accepted for normal schooling where it was noted that she had poor social skills and was shunned by other children. Because of educational retardation and these severe social difficulties, as well as continuing temper tantrums, Brenda was placed by the Army psychiatrist in a special boarding school for maladjusted girls. Every week, after her weekend at home, she became hysterical at the thought of returning and the parents were distressed at having to compel her. The G.P. had been called on these occasions, and described poignantly Brenda’s seeming agony and intense anger. No drugs seemed to touch her.

The parents came to see me alone, I thought probably to vet me. I arranged for psychological assessment to help with the schooling decision. Brenda was of dull average intelligence and adequate attainment ; the psychoIogist and I felt that the boarding school decision, taken when the family were abroad and not able to avail themselves of special day schooling, was no longer appropriate and she returned home to a small day E.S.N. school where she is doing well and where individual attention can be given. Brenda was much happier and the parents then asked €or help with her temper tantrums and the tormenting behaviour she showed to her brother, as well as her social difficulties. A contract for family therapy was offered and accepted.

First family meeting M a y 1978

This was the first time I had met Kevin who looked strikingly like Brenda. They were both fair haired and could be taken for twins in size and facial characteristics, even though unrelated genetically. He was seen as a gentle, articulate boy, who was a great help in the family interview. They had brought their star charts. Kevin was on one too, getting a reward if he did not retaliate when Brenda tormented him. Brenda had done very well, and there had only been two torments in the last two months since it had started. There had also only been two temper tantrums, and she had managed to control these. The parents had really got the hang of the star chart method, and were using it very effectively, and we went on to talk about the need to increase Brenda’s social skills, because Kevin had been so embarrassed at Brenda’s outspoken questioning me of my private life.

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Although Brenda started out in a quite cheerful, outspoken way, she gradually relapsed into a thumb sucking, face hiding sullen withdrawal and I questioned this. Mother felt that it was to do with the fact that we were talking about her, but that did not seem a good enough explanation, and after a bit of guessing I got at the cause of it. I n fact my guessing was so accurate that Brenda was amazed, and said I was very clever. I said something about not being very clever because lots of people had these feelings. Brenda immediately contradicted me and said ‘you are’. The problem that we had been discussing was the fact that Brenda found it difficult to let mother out of her sight, even for mother to go to church, or to go out in the evening, and that for the parents to go out together was almost impossible, because of the difficulty of finding a sitter who could cope with Brenda’s misery when the parents were not there. She also did not seem very comfortable when she was alone with Dad, and at first the family seemed to think that this was because Dad was better at cutting off, and watching television, and did not give her his full attention like mother did. But as we went on, it seemed to me to be more to do with some fear that Dad would not be able to look after her monster-like fantasies. I put this into words, and Brenda nodded dumbly. I said I thought something must have happened to her perhaps a long time ago, which made her feel frightened that these monster feelings might get out of control, and damage somebody she loved, and she said ‘maybe it was my burn’. The parents then told me about how she had been in hospital for a week with a growth on her neck, when she was eighteen months, and they had not been allowed to visit or stay with her-it had been an army hospital. Then when she came home, father had been looking after her, and she had pulled a hot cup of tea all over her and had a burn. I invited the whole family to try to get inside the skin of the baby Brenda and imagine the feelings she had of abandonment, and the rage she must have felt towards those who had abandoned her, particularly as this had been not her first, but her second experience of what must have seemed like abandonment to her. The rage was directed towards mother as the person who nurtured and then abandoned her, but the feeling was that Dad could not look after those bad feelings because somehow he had let them hurt Brenda too when she was burned. I said to Brenda that there was that little baby bit inside her that was still frightened that those rage-like monster feelings would hurt her mother, if she was not around to look after her mother and protect her.

1 said I thought that perhaps Mum sometimes found the rages that Brenda had had more than she could bear, and wanted to be away from them for a time, and that had only confirmed the feelings Brenda had that Mum was harmed by them, and I asked if mother ever did anything like

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that. Mother denied it, but then Kevin reminded her that she had, and I said that of course it was inevitable because she was only human.

Second family meeting July 1978

The family were very happy-Brenda had let her parents go out for the first time ever without feeling miserable. They had abandoned the star charts because Brenda had got cross about them, but she had really man- aged to continue to keep her temper under control, and on the whole the tormenting. She had made great gains in her swimming, and in fact had the makings of a very good swimmer.

Mother raised the problem that Brenda has very persecutory feelings. It is almost as if she feels that her mother is wishing actively to harm her, so that it is difficult for her mother to set limits or deny her things, although she is really quite good at doing it. Father has been coming in more, particularly since he left the Army, to take her swimming every Sunday morning etc.

I explained that her two mothers were confused in Brenda’s mind, so that sometimes she felt her to be a mother who really was persecuting her. Mother said she had never really talked about Brenda’s early days, but perhaps that this was the time that we should do it. Brenda knew that she was once called May and that her mother had many other children, and she knew that her mother could not look after her, but she did not know any more than this. I said that Brenda’s mum, when she was born, had not been able to look after her as a baby at all, and for the first few months af her life Brenda had really been very very unhappy. When she cried her mum had not been able to come to look after her, and when her mum did come Brenda had been crying so much that she could not stop and then her mum had hit her to try and make her stop. This was not because her mum had been cruel, but because she had been busy because of all the children she had, and because some mums are better than others at being able to cope. Brenda hid her face when I was talking about this, but Kevin was listening very hard.

After this meeting Brenda was quite withdrawn and sad but also seeking for clarification-asking her mother questions about her babyhood that she had avoided before. She said she wanted to work on her difficulties at school in getting on with other children and we arranged some sessions with a clinical psychologist who used video play-back and role play with Brenda and her mother to improve her social skills. The family therapy sessions continue. Kevin feels that he and Brenda get on better now because he understands what she has experienced and he is more tolerant. Brenda

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is almost ready to transfer to a comprehensive school and her behaviour is within normal limits.

Comment

There is no doubt that Brenda’s own intrapsychic difficulties were the major problem here but it was their effect on the family and the effect that family participation in treatment could have which made me choose family therapy rather than individual therapy. In session one I used many techniques belonging to individual therapy including interpretation and imaginative reconstruction of the past, but also behaviour modification techniques for working on the tormenting and tempers with both children getting rewards and eventually social skills training. Kevin’s excitement when he could make sense of Brenda’s behaviour by reminding mother of her own rejecting behaviour was palpable. The advantage of having the whole family together is that they can all begin to understand that they interact. The effect on this family has been to improve communications- mother has no longer felt the need to protect Brenda from the knowledge of the failed first mothering experience and this enabled Brenda to sort out which feelings belong to which mother. The improvement in her func- tioning is striking as is her wish to work on her social problems.

Case No. 2

William 64 years was referred by the school because of learning difficul- ties, aggressiveness and soiling (which occurred chiefly at home).

Famiiy Father 39

Mother 37

Darren 12

Labourer on sick leave for eighteen months because of hospitalization and multiple operations. He was stabbed by his brother following a fight over mother. Obese, inarticulate, from a violent, chaotic background. A housewife. An attractive, young-looking woman in her second marriage. Her dominant feelings were of failure as a mother (her two children by a previous marriage had been taken into care after running away and persistent delinquent activity) and antagonism to authority. Her background too was disturbed and previous agencies have intimated that she had been a prostitute. Placed at boarding school for maladjusted children by an- other psychiatrist because of delinquency, aggressiveness and running away.

Family therapy as setting for other treatment modalities 189

Children of mother’s previous marriage, in care in children’s

family for some time. Both very disturbed. My heart had sunk at this referral. I had been consulted

five years previously by social services about Peter, whose moodiness and disruptive behaviour in the children’s home had been unmanageable. I had never succeeded in meeting the parents, in spite of offering home visits, and the treatment I arranged (intensive psychotherapy from a child analyst plus counselling the children’s home staff by psychiatric social workers) had been unsuccessful. When Darren had been referred I arranged for him to be seen by a colleague, who had since left the clinic.

The family of three came together. William was a timid, fearful boy, whose soiling seemed to be due to diarrhoea out of fear, rather than aggressive, deliberate voiding of formed motions. He had a history of birth difficulties, and discrepancies on I.Q. testing suggestive of possible brain dysfunction. He was hyperactive, distractable and lacked concentration, and his attainments were nil. The parents talked about the fight in which father got injured. His brother and mother were having an affair and she left her husband. Father got mother back and his brother stabbed him in the chest. He nearly died, and was still convalescing eighteen months later. The brother was due out of p rlson . in a few months time and the family were planning to ‘disappear’.

William had witnessed the fight and had been soiling since then. He shrank at the retelling of the story. Mother was hostile, and said: ‘I only come once to these places’, challenging me to find a solution acceptable to her.

homes for many years, and having had no contact with the

What I had to do here was to find a way of giving these parents some success with the last child at home in view of their feelings of failure. The chaos, violence and hostility in this family made me feel the need to structure and order the situation so I set up a behaviour modification programme for the soiling, using rewards rather than punishments and at the same time got the parents to clarify to William what their plans were when the brother left prison-up till now they had kept it secret from fear of someone telling the brother their plans. For his hyperactivity, distractability and learning problems I prescribed methylphenidate

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medication. I emphasized that they were all to participate in the behaviour modification programme and that they would be doing the treatment. T o my surprise and pleasure they kept the next appointment, to report that William was completely clean and had begun to read, to thank me, to say goodbye because they were moving, and to request transfer to the local child psychiatrist.

Comment

The combination of behaviour therapy, drug therapy and family therapy, produced a marked shift in this disturbed family in only two sessions which one hopes will lead to this boy being more rewarding to the parents than the other children. It should also make them more willing to seek help than they have been in the past.

Case No. 3 Jane 12 years. Referred while an inpatient of the paediatric ward because of severe weight loss, not due to any organic cause.

Family Father 45

Mother 42

Ellen 7

Dustman, elderly-looking plump, quiet spoken, poor with words. Came froma close knit, East End, working-class family and still spends a lot of time with them. Plump, cheerful woman, worked part time in school meals. Convinced that Jane had some wasting disease. Had kept her off school with minor illnesses all the year (sore throats etc.). Plump, shy, inarticulate miserable girl. There had been several recent deaths in the family and a family history of violence (Father’s brother-in-law had beaten up Father’s sister-Father much involved). A diagnosis of Anorexia Nervosa was established and family therapy offered.

Jane stayed on the paediatric ward until her weight had been restored, using a behaviour modification programme adapted from Bhanji and Thompson (1974). Family therapy sessions began with a meal which the paediatric registrar, medical social worker and I ate with the family. Mother coaxed Jane who ate each morsel at a snail‘s pace, complaining how full she felt. We gave father, who had been passive up till now the task of getting Jane to eat [see Rosman et al. (1975)l and he broke down in tears confessing his fear that he would lose his temper with her and do her damage. His brother-in-law had hurt his sister and father had

Family therapy as setting for other treatment modalities 191

had to restrain him. We defined the difference between assertion and aggression, firmness and violence and left him to get Jane to finish the meal which she did. In further sessions we encouraged father to set limits for Jane and she began to eat well, losing her anorexia and her fear of gaining weight. On one year follow-up she remains healthy and well-nourished. Mother took a back seat and stopped fussing about Jane’s minor illnesses.

Comment

Jane could not negotiate a developmental stage into adolescence unless helped to free herself from mother’s overprotection by father. He had until then abdicated this role through fear of the consequences of his anger; consequences which had become a reality in his close extended family. We used successful strategies to change the family structure and enable growth to occur.

Discussion

There is little written about the use of other treatments in family therapy settings. Alexander and Parsons (1973) did a controlled, comparative study of short term behaviour therapy in family meetings. The probands were families containing a delinquent adolescent and they used three matched control groups which included psychodynamic family therapy alone, and a ‘no treatment’ group. They found that family therapy alone did not reduce recidivism but the combined treatment did, the recidivism rates in the probands being 26% compared with 73% in the psycho- dynamic family therapy. The authors emphasize that their goals of increasing family reciprocity and clarifying communication utilizing contingency contracting are more effective in delinquent families than insight-promoting family therapy without clearly defined goals. Using parents as change agents for their children [see Johnson and Katz (1973) for a review] and siblings as therapists (Miller and Cantwell, 1976) have been reported. Psychoanalytic writers, Shapiro et al. (1977) and Bruch (1974) have recognized the value of family therapy as an adjunct to individual therapy but I can find no accounts dealing with intrapsychic problems in family therapy. Several authors have used combinations of family and behaviour therapy but the latter was done with the individual child alone and not in the family group (Rosenberg and Lindblad, 1978; Fine, 1973). My own experience has led me to be flexible and not to discard lightly the knowledge and skills acquired during my professional life. I believe that the three families I have described (and others) have

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benefited from this eclectic approach of combining therapies in a family setting. The approach is an economical one--only one therapist is used who can be expert in many forms of treatment and use them flexibly and in combination. The family sees the treatment as their responsibility so that co-operation and involvement are maximized.

References

ALEXANDER, J. and PARSONS, B. (1973) Short term behavioural intervention with delinquent families. Journal of Abnormal Psychiatry, 81 : 219-225.

BHANJI, S . and THOMPSON, J. (1974) Operant conditioning in the treatment of Anorexia Nervosa. British Journal of Psychiatry, 124: 166-172.

BOWLBY, J. (1969) Attachment and Loss, 1. London. Hogarth Press. BOWLBY, J. (1975) Attachment and Loss, 2. London. Hogarth Press. BRUCH, H. (1974) Eating disorders obesity. Anorexia Nervosa and the Person

CAPLAN, G. (1961) An Approach to Community Mental Health. London. Tavistock

FINE, S. (1973) Family therapy and a behavioural approach to childhood obsessive

HALEY, J. (1976) Problem Solcing Therapy. San Francisco. Jossey-Bass. JOHNSON, C. A. and KATZ, R. C. (1973) Using parents as change agents for their

MILLER, N. B. and CANTWELL, D. P. (1976) Siblings as therapists: a behavioural

MINUCHIN, S . (1974) Families and Family Therapy. London. Tavistock Press. ROSENBERC, J. B. and LINDBLAD, M. B. (1978) Behaviour therapy in a family

context: treating elective mutism. Family Process, 17: 77-82. ROSMAN, B. L., MINUCHIN, S. and LIEBMAN, R. (1975) Family lunch session: an

introduction to family therapy in Anorexia Nervosa. American Journal of Orthopsychiatry, 45: 846-853.

SHAPIRO, E. R., SHAPIRO, R. L., ZINNER, J. and BERKOWITZ, D. A. (1977) The borderline ego and the working alliance: indications for family and individual treatment in adolescence. InternationalJournal of Psycho-Analysis, 58: 77-87.

SKYNNER, A. C. R. (1976) One Flesh: Separate Persons. London. Constable. WINNICOTT, D. (1971) Therapeutic Consultations in Child Psychiatry. London.

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