Child Psychiatry and Family Therapy An Overview
Charles A. Malone, M.D.
Abstract. The polarization which has characterized the relationship between child psychiatry
and family therapy no longer dominates the interrelationship between the two fields as it once did. Increasingly child psychiatrists are employing family therapy in their clinical work and discovering the valuable contribution the two fields can make to each other. This paper attempts to explore this fruitful interrelationship by reviewing the usefulness of family therapy in relation to diagnosis, treatment, and crisis intervention and by discussing the role of children and the value of dynamic and developmental concepts in understanding core clinical issues and therapeutic change in family therapy.
Historically, and even currently, there have been considerable conflict and polarization between child psychiatry and family therapy (Brown, 1972; McDermott and Char, 1974). Psychoanalytically oriented child psychiatrists have opposed or resisted family therapy on the grounds that it contaminates the transference or interferes with needed confidentiality in child treatment. They have been concerned about the traumatic effects on children of being explicitly confronted with implicit dangers in their intrafamilial relationships-such as the hostile rejecting feelings of a parent. On the other hand, family therapists (Ackerman, 1966; Kramer, 1968) have been concerned that isolated treatment of the child ignores the sources of the child's disturbance in pathological family patterns, in marital discord, and in the parents' own problems. The sources of this conflict and polarization are multiple. To begin with, there is often a contradiction and fundamental antagonism between family therapy and child psychiatry in that some family therapy theories and techniques implicitly or explicitly ignore individual psychology and psychosexual development, and
Dr. Malone is Professor and Director, Division of Child Psychiatry, Case Western Reserve University School of Medicine and University Hospitals of Cleveland (2040 Abington Road, Cleveland, OH 44106), uihere reprints may be requested.
0002-7138/79/1801-004 $01.51 e 1979 American Academy of Child Psychiatry.
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oppose dynamic principles such as unconscious conflict and motivation. Many family therapy theories conceptualize the symptomatic child as an extension of disturbance in the family system without appreciating the child as a person in his own right (A. Freud, 1972). This is exemplified by family therapy approaches which insist on always seeing the whole family and rule out seeing individual family members, or which focus only on the parents and rarely, or never, include the symptomatic child (Bowen, 1966), even if that child is "very disturbed" (Beels and Ferber, 1972). The various fragmentary, often conflicting, theories of family therapy are difficult to integrate with each other and even more difficult to integrate with analytic meta psychology and developmental concepts. The task of integrating the fragmentary, disparate theories of family therapy with dynamic developmental concepts is complicated by the fact that the process of studying families is extremely difficult. It is difficult to do justice to the complexity and range of family transactions in the process of conceptualization and theory building without risking oversimplification which loses the essence of what transpires in family life. Describing and understanding the reciprocal influence of the intrapsychic developmental needs of individual members and the transactional patterns of the family system are almost insurmountable tasks (Anthony, 1973). The extraordinary complexity of the conceptual task involved, coupled with the pain and frustration of the clinical task of treating serious child, adolescent, adult, marital, and family psychopathology, often leads to defensive disengagement and polarization. Polarization to one theoreticaVconceptual model is usually coupled with intellectualization and rationalization as the merits of one approach versus another are argued, while neither approach is studied and the overwhelming and threatening aspects of severe child and family pathology are avoided and ignored. The polarization between child psychiatry and family therapy reflects in many ways the long-standing internal/external dichotomy and the sterile nature/nurture controversies which have plagued the behavioral sciences. Finally, conflict and polarization between child psychiatry and family therapy have been produced by leaders in each field who foster polemic positions and insist on loyalty from their followers. The considerable overlap between family therapy and child psychiatry is ignored, while differences are emphasized. Thus, some leaders in child psychiatry overgeneralize child analytic techniques to all forms of child treatment and oppose family therapy,
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even though Freud pointed to the importance of family factors in childhood psychopathology (Sander, 1973), and the well-established tradition in child psychiatry of understanding and treating children in relation to their past and current family relationships. Correspondingly some leaders of family therapy use dynamic developmental concepts without acknowledging or even denying any connection to their work. For example, although developing independence through differentiation of the self from the "undifferentiated family ego mass" is central to Bowen's conceptualization of family therapy (1966), he steadfastly avoids relating this clinical process to the separation-individuation process described by Mahler and her colleagues (1975). While the polarization between child psychiatry and family therapy still persists and will continue, it no longer dominates the relationship between the two fields as it once did. Many child psychiatrists and family therapists have been able to move beyond such dichotomous polemics and to take a middle position in which internal and external are seen as inseparable and intrapsychic and interactional forces are viewed as interrelated and interdependent. According to this view, while conflicts which may provide the basis for later pathology arise in the first place in interactions with the demands and prohibitions of the parents, it would be an error to ignore the fact that children interact with parents on the strength of their individual characteristics and innate endowment. Similarly, as Anna Freud (1972, p. 622) observes, "No child should be approached, assessed, treated, nursed, taught, corrected, etc., without taking the parental influences into account, and that without knowledge of their impact neither the child's developmental successes or failures nor his adjustments or maladjustments will be seen in their true light" (my italics). According to this view, psychological development and functioning is a reciprocal intergenerational family process. Families even develop what Anthony (1973) calls "a family likeness" in which members of the same family display the same personality characteristics, coping styles, prejudices, defense mechanisms, and symptom clusters when they fall psychiatrically ill. Increasingly, child psychiatrists have employed family therapy in their clinical work and have applied it to a wide range of issues and tasks. In recent years, the number of child psychiatrists using family interviewing for diagnostic and therapeutic purposes has increased dramatically. Some indication of this growth in interest can be seen in a 1976 survey of over 900 members of the Academy of
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Child Psychiatry which revealed that the majority of those surveyed 1 use family interviews in their clinical work-only 8% never use family interviews for diagnostic purposes and only 12% never use family interviews for treatment purposes. Child psychiatrists doing family therapy have become aware that the knowledge base and clinical skills of child psychiatry play an important and, at times, critical role in their ability to carry out effective family therapy. They have learned that their emphasis on careful diagnosis, knowledge of child development, appreciation of the child's contribution to his own and the family's problems, and ability to utilize the fantasy, play, and verbalizations of children are all crucial to the conduct of family therapy. Family life plays a major role in the development of psychic structure, which in turn shapes family life, through mechanisms such as externalization (Brodey, 1959) and projective identification (Klein, 1946). Object relations theory in particular addresses this issue in its concern with the way in which children internalize their parents as models and how these models influence and are influenced by subsequent relations with significant others in the environment. Dynamically oriented child psychiatrists are keenly aware of the value of psychoanalytic insights in making sense out of the complex data involved in family transactions, in judging the indications or contraindications far family treatment, in devising useful applications of family therapy, in choosing between alternative intervention strategies, and in achieving some degree of order in their thinking about the multiple, diverse, and at times contradictory approaches used in family therapy. In relation to this latter point, Ackerman (1972), in commenting on the diversity of family treatment approaches and the lack of sufficient knowledge regarding family dynamics and diagnosis, bemoaned "the lack of a unified theory in family therapy" and the adverse effects on family therapy of the "preoccupation with experimentation in therapeutic techniques" (p. 445). The field of family therapy is no further along in relation to the development of a unified theory at the present time. Knowledge of family dynamics and diagnosis has to a considerable extent been impeded by the adynamic, adiagnostic quality of many family sysI The survey was responded to by 64 % of the Academy membership with an age. geo· grahical , and practice setting range representative of the Academ y's total membership (Survey Report, Committee on Famil y Therapy, American Academ y of Child Psychiatry, 1976).
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tems approaches. It has also been delayed by the state of our limited knowledge of family development and the range of adjustment that constitutes "healthy" family life. In addition, as indicated earlier, the historic, cumulative, and ongoing interrelationships between intrapsychic and interpersonal forces and how these impact upon and are influenced by the family system are extraordinarily complex. Nevertheless, some of the fragmentation and diversity in regard to family therapy seem unnecessary even with the limitations of our current knowledge. As Ackerman (1972) pointed out, "close scrutiny of contemporary trends in family therapy leads to the impression that the multiple approaches which characterize this field do not in fact represent pure or distinct forms of treatment" (p. 446). There is significant overlap between family therapy approaches and common themes among the concepts utilized to explain these approaches. Exploration of certain aspects of what each field can contribute to the other serves to emphasize the fruitful interrelationship between child psychiatry and family therapy which has been developing in recent years. Since more has been written about the contributions of family therapy to child psychiatry, I will simply review its usefulness in diagnosis and treatment and its applicability to a single clinical task-s-crisis intervention. Since less has been written about the contributions of child psychiatry to family therapy, I will devote more attention to that subject, commenting on the role of children in family therapy and discussing dynamic developmental concepts in relation to core clinical issues and therapeutic change in family therapy. CONTRIBUTIONS OF FAMILY THERAPY TO CHILD PSYCHIATRY
Clinical experience with family therapy increasingly demonstrates its usefulness in diagnosis and treatment and its applicability to a broad range of clinical tasks (Brown, 1969, 1972; Malone, 1974; Skynner, 1969; Williams, 1968). In relation to diagnosis, family interviews enable us to assess how a child's symptoms or dysfunction are influenced by and influence the family system. When family interaction is skillfully facilitated, the presenting problem actually happens in the here and now of the family interview. This provides an opportunity to observe not only family reactions and contributions to the problem, but also the balance of capacity and motivation for or against change in the family as a whole (Skynner, 1969). This enables us to insure the involvement of the psychologi-
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cally relevant family members who collusively or openly are part of and contribute to the problem, or to avoid at the outset an interminable treatment working with only part of the family involved in the problem. While family interviewing helps us to assess a child's general functioning in the family context, it is particularly useful in determining the nonverbal communications which contribute to a child's impulsivity and poor behavioral control, modes of expressing and monitoring affect, overstimulation or understimulation in relation to drives, response to parental demands and prohibitions, defensive and coping processes, identifications, and the quality of his intrafamilial relationships. Family interviewing is particularly helpful in reducing guilt and fear in parents and children, in bolstering self-esteem especially in the identified patient, and in countering loyalty conflicts or secret-keeping that block open communication. Family interviewing enables us to identify the family's characteristic patterns of communication, affect expression, relationship and role, problem solving, and conflict resolution. Finally, family interviews are particularly useful in identifying structural imbalance (scapegoating, splitting, alliances, collusions, symbiotic or sadomasochistic dyads, role reversal, etc.), patterns of projective identification, and underlying marital, parental, and family of origin problems. In relation to treatment, providing one employs a flexible approach (Ackerman, 1958; Malone, 1974) that allows for combining family therapy with individual or marital treatment, concomitantly or in sequence, depending on clinical indications, the usefulness of family interviewing is very broad. Some of the usefulness of family therapy derives from general advantages which it has (Malone, 1974). Family therapy offers more direct therapeutic access to acting-out and symptomatic behavior. It increases the therapist's ability to recognize and counter the secondary gain which the child's symptoms provide for parents, siblings, and the child himself. It increases therapeutic potential by offering a means of identifying and enlisting healthy members or aspects of the family. Finally, it keeps responsibility for problem solving within the family so that, if progress occurs, everyone changes and a new equilibrium is reached (Skynner, 1969). While the indications or contraindications for family therapy in child psychiatric services are still being worked out, clinical experience does suggest useful guidelines. The indications for using family therapy relate closely to the ways in which family interviewing is useful diagnostically. Hence, family therapy is particularly useful in
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treating developmental delays and certain types of presenting problems in children, in modifying relationship and role imbalance, in dealing with un mourned losses or an actual or impending family crisis, in countering scapegoating and the use of a child's symptoms as a conflict-detouring mechanism, in dispelling myths, divisive secret-keeping, and other chronic intrafamilial communication problems, and in working with families dominated by projective identification or where marital, parental, and/or family of origin problems underlie the child's presenting problems (Malone, 1974). In relation to developmental delays, the kinds of problems that may be particularly well suited to or require family treatment are hyperactivity, excessive aggressiveness, failure of urinary or bowel training, severe sibling rivalry, excessive separation anxiety, and failure to develop effective speech (Brown, 1972). Among the presenting problems where family treatment is helpful are: childhood emotional, social, behavioral, and learning disturbances where family interactional patterns contribute to ego or superego dysfunction and/or overstimulation of aggressive or sexual impulses; chronic illnesses with moderate to severe secondary emotional disturbance and developmental interference (such as hemophilia and cystic fibrosis), and psychosomatic illnesses (such as juvenile diabetes, asthma, anorexia nervosa, and functional GI disorders); and children and adolescents who act out ("delinquents" who act out parental impulses or ego-syntonic character disorders), or who have notable separation problems. In addition, because of its general advantages, family therapy is also valuable when combined with individual therapy, in furthering the psychotherapeutic process in relation to children suffering with moderate to severe intrapsychic problems (Malone, 1974). Thus it can be an invaluable aid in the treatment of precisely those problems for which analytically oriented psychotherapy is usually best suited and most effective. In terms of limitations and contraindications, family therapy is not useful when the very process of focusing on family transactions intensifies and perpetuates the pathological patterns within the family without prospects for repair. This is the case in families where one of the parents has severe problems (depression, masochism, paranoia, psychopathy) and is particularly resistant, and the rest of the family cannot become involved in treatment without risking a breakup of the family, which they are unwilling to do. This is also the case where there is a dominance of sadistic gratification and destructive behavior in a family, such as physical and psychological abuse, and there is not enough discomfort to
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motivate the family to change. Similarly, while family interviews and treatment can be very useful in relation to marital separation, family therapy is not indicated and may be harmful when the separated or separating parents have an extremely hostile relationship which is set off by each other's presence. When a firm decision to divorce has been reached, bringing the estranged couple together in family treatment runs counter to their psychological task of separating and relinquishing and working through their ambivalent attachment. Despite this, however, some structured family interviews may be helpful or necessary when the children are being caught in the middle of the divorcing or divorced couples' continuation of their marital battle (Malone and Gispert, 1977). While family therapy is often indicated for adolescents with separation problems, there are times when seeing adolescents with their parents perpetuates rather than counters pathological dependency or symbiotic ties. Similarly, with older adolescents preoccupied with and in the process of disengaging and emancipating from the family, family treatment often runs counter to the adolescent's developmental needs. In relation to the many valuable applications of family therapy to clinical tasks the use of family interviewing and family therapy in ' crisis intervention is a good example. There are many acute, nonrecurrent stresses and crises in the lives of individuals, couples, and families, where several or a series of family interviews are extremely helpful. This brief intervention may lead to family therapy; sometimes, however, family therapy is not possible and may not be indicated. These acute nonrecurrent stresses and crises may involve phases of critical change in family life such as marital separation or transitions such as an adolescent leaving home. They may involve acute, serious physical or mental illness and hospitalization, or life events such as a premature birth or the death of a parent, sibling, or child. Family interviews at such times of crisis enable us to identify the life-style and values uf the family as well as its patterns of relationship and role, communication, affect expression and control, defense, coping and problem solving as these relate to the situational stress. The crisis can be evaluated in terms of the emotional strain on each member, the mobilization of intrapsychic as well as interpersonal problems, and the intrafamilial, extended family, and social network resources available for meeting and resolving the crisis. Family interviews offer an opportunity for members to share information, ventilate feelings, and clarify affective or cognitive confusion or distortion about the event itself.
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This reduces the possibility of acting out guilt and anxiety in provocative behavior and the use of such mechanisms as projection, displacement, and scapegoating. Since these crises involve both actual and threatened losses, a crucial aspect of the clinical work involves the encouragement of a grieving process. Family interviews and family therapy facilitate this process by countering avoidance or the institution of massive defense and by assisting family members to face and master the painful, personal-interpersonal feelings involved. CONTRIBUTIONS OF CHILD PSYCHIATRY TO FAMILY THERAPY
Child psychiatrists who are family therapists have long been aware of the many ways in which their child psychiatric knowledge base and clinical skills are crucial to the conduct of family therapy. At the most fundamental level this involves their ability to include children of all ages and to understand and utilize children's play, fantasy, and verbalizations in family diagnostic and treatment process. The inclusion of children in family therapy has many important ramifications. It is essential to include the "well" siblings. They are needed to point up family problems outside the index patient and thus to counter the devaluation involved for the child labeled as the patient in the family. They may well have problems in their own right and may, in fact, be more disturbed than the index patient. The "well" siblings may be part of a family pattern of scapegoating or be in a parental child role. On the other hand, since the index patient and the parents are usually locked into chronic repetitive patterns, the "well" siblings are often more independent and objective and therefore able to observe and identify family patterns and problems. Younger children in particular are often more direct and open, less defended and "sophisticated," and therefore more apt to express the feelings and conflicts which underlie family transactions. Sometimes siblings serve as a family spokesman in getting to the core interpersonal issues within the family. Including children of various ages has many advantages. The therapist is able to observe the response of family members to children at different stages of development. This contributes valuable information about the difficulties or resourcefulness of parents and children regarding phasic developmental issues. At the same time this offers the therapist opportunities to present models of interaction, communication, and response to children with dif-
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ferent developmental needs which can provide possibilities for corrective emotional experience. The inclusion of young children naturally leads to focusing on play and fantasy and their expressive and defensive use (Skynner, 1976; Zilbach et aI., 1972). Older children bring their experience in the world outside to the family and may be able to "coach" younger siblings in meeting the challenges of school, neighborhood, or peer group. The value of child psychiatric knowledge goes well beyond the ability to understand and utilize the role of children in family therapy, however. The dynamic developmental orientation of child psychiatry has implications in relation to understanding and treating core clinical issues that repeatedly appear in family transactional process and in relation to understanding aspects of the therapeutic change which occurs in family treatment. Dynamic Developmental Concepts in Relation to Core Clinical Issues in Family Therapy
A ubiquitous theme in the conceptualizations of many leading figures in the field of family therapy (Bell, Bowen, Brown, Kramer, Nagy, and Paul), regardless of their theoretical orientation, involves the various ways parents can carryover unresolved conflicts and losses, organizing views of self and others, identifications and roles from their family of origin into their nuclear family life. These ghosts from the past affect or dominate marital choice, the character of the marriage, parental functioning, and parent-child and family interaction. All those who do family therapy are familiar with the clinical process of starting with the family's focus on one child who is symptomatic and working back through the complex network of projections, displacements, and identifications, to the parental, marital, personal, and family of origin problems which underlie the family's initial concerns. As a part of this clinical process the therapist brings to the family's awareness complementary patterns involving projective identification (Wynne, 1965; Zinner and Shapiro, 1972), in which an unwanted part of one parent is projected onto and identified in a spouse or a child who in turn develops attitudes and behaviors which complement the projection. This mechanism operates in a similar fashion to reciprocal role expectations and serves to keep intolerable qualities, ideas, and feelings out of awareness while retaining these qualities, ideas, and feelings within view at a psychologically safe distance. This mechanism usually leads to a powerful collusive interdependent system of forces in the family. Depending on their extent and
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chronicity, these complemental interlocking patterns of projective identification interfere with undifferentiated independent functioning of famil y members and create varying degrees of individual and interpersonal problems and of pathological family enmeshment and lack of differentiation with concomitant problems related to separation anxiety . With individual variations, many family therapists conceptualize their approach to family therapy in terms of assisting family members to break pathological symbiotic and dependency ties and to separate and differentiate themselves from famil y enmeshment in order to achieve effective independent functioning. Thus Ackerman and Behrens (1959) speak of separation and differentiation from the parental matrix, while Bowen (1966) emphasizes the process of differentiation of spouses from each other and a pathologically dependent symbioticlike "emotional oneness." Satir (1964), while she presents herself to families as an expert in and teacher of communication, is also committed to helping each family member experience "individuation." Boszormenyi-Nagy (1965), who has developed perhaps the most ambitious integration of obj ect relations theory, ego psychology, and transactional process, has as a corne rsto ne of his approach the uncovering of distorted partobject introjections and projections of parents within the nuclear family. Finally, Paul (1967) and Paul and Grosser (1965) explicitly organize family treatment as a process designed to exorcise the ghosts from the family of origin which dominate the life of the nuclear family. Paul attempts to uncover the effects of the unrelinquished object, usually an un mourned loss of a parent or sibling, on cu r re n t famil y life and to ca rry out a process of mourning and relinquishing. Interestingly, in this process the therapist presents himself as a model of empathy which is a healthy form of projective identification and also utilizes nonverbal communication and role modeling. These conceptualizations of the process of family treatment explicitly or implicitly lean heavily on object relations theory and the separation-individuation developmental process. Where parems carryover attachments, conflicts, and unresolved losses, organizing images of self and other, identifications, and roles from their family of origin, they are expressing ideas, feelings, fantasies, behaviors, and models experienced, learned, and internalized in childhood . Such parents , at least in specific areas related to the unrelinquished ties and/or unresolved conflicts with parental objects, have not achieved a full degree of separation and individua-
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tion from their own parents. The more incomplete the separation process, the more dependent and undifferentiated or symbiotic that parent's object relations will be and the more he or she will rely on projection, introjection, and splitting mechanisms. Object relations theory concerns itself with the way children internalize their experience with their parents and significant others, forming an inner world of self and other object representations which serve as models for current and future behavior in relation to the parents or other authority figures and for role functioning in later life. The separation-individuation process is intertwined and interrelated with the process of internalization of self and other object representations (Mahler et al., 1975). When individuals achieve full autonomy they not only have successfully internalized stable differentiated models of self and others which can be modified or corrected by experience, but they also have achieved a degree of independence and conflict-free functioning which enables them to meet new situations and people without necessarily having to repeat their inner models. When separationindividuation is incomplete, the individual cannot differentiate himself sufficiently from his inner models and tends, or is compelled, to repeat them. In addition, the models internalized include maladaptive and pathological relationship experiences with parents and significant others which usually are not modified or corrected by experience. This ultimately sets the stage for the kinds ofinadequately differentiated maladaptive personal-interpersonal motivations, behaviors, defenses, and relationships that profoundly affect marital choice, marriage, parental functioning, and family life and which so frequently are and have been the focus of family therapy. In relation to the therapeutic issues involved in attempting to assist families to resolve maladaptive object relations related to developmental deficits in the separation-individuation process, Bowen (1966) observes that with certain families where differentiation of the marital couple is not possible, he is willing to work with the healthier spouse. However, he cautions that if the work is successful and the treated spouse is able to differentiate, he or she must be prepared for distressing reactions in his or her mate. The most profoundly threatening of these reactions involves withdrawal with the implicit or explicit concomitant threat of separation. In response to this the treated spouse is likely to get depressed, confused, and develop a whole spectrum of physical symptoms. As Bowen puts it (1966, p. 189), "this is the reaction of one's psyche
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and soma as it cries out for the old dependence and togetherness." In order to maintain the change achieved and evolve a new balance in the marriage, the treated spouse must be able to tolerate the depressive affect and anxiety engendered by the threatened loss of attachment implicit in the mate's strong resistance to the change and reaction of withdrawal. Brown (1969) places these issues into a broader perspective which includes children. He notes that patterns of interpersonal relationship in families often protect inner models from being al-. tered by real events. Therefore significant change in family members and intrafamilial relationships produces or threatens to produce a partial internal loss (relinquishing of internal self and other object representations or models) and is resisted and/or reacted to with separation anxiety and grief. Thus, change in a wife engenders anxiety in a husband which may lead to a new surge of overinvolvement with the symptomatic child, who also reacts to the change in his mother as an actual or threatened loss and may temporarily regress and become more infantile and demanding, which in turn reinforces and is reinforced by the father's overinvolvement. These events in turn exert a strong pull on the wife/ mother to return to her old patterns. Family therapists must anticipate and be prepared to help family members recognize resistance to change and work through threatened and actual object relationship losses which are inevitably associated with significant change in family members and intrafamilial relationships, or else the change will not last or will not be beneficial to the family. Thus, whatever language he frames his understanding in, the family therapist who intends to help a symptomatic child by removing the influence of underlying marital, parental, or family of origin problems must appreciate the psychology of attachment, separation, and loss, the relationship between inner models and external intrafamilial relationships (in both parents and children), and that resistance to change involves not only a counterreaction to a shift in the family homeostasis, but expectable psychological responses to threatened and actual object and part object loss. Dynamic Developmental Concepts in Relation to Therapeutic Change in Family Therapy
Corrective emotional and object relationship experience (Alexander, 1957) has long been recognized as being significant in psychotherapeutic change in both adults and children. Child psychiatrists who are family therapists have frequently pointed to
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the significant advantage of family therapy in relation to corrective emotional experience in work with children (Williams, 1968). In individual therapy children often reproduce aspects or essential qualities of their troubled or pathological relationship with a parent. They project their inner models of self and parent onto the therapist and the interaction with him or her. Although the therapist may attempt to correct the child's view and experience of himself by not following the projected model and behaving and relating differently from the parent, such corrective experiences may be negated or undermined by the child's continuing intrafamilial experience with the parent and other family members. Family therapy offers not only a means of countering the undoing of corrective emotional experience, but, more importantly, of producing actual change in the parents (often through their own corrective experience and identification with the model of the therapist). Thus, the model of parent-child interaction changes, directly producing a much more powerful corrective emotional experience. This leads to a consideration of the subject of therapeutic change which is the focus of considerable controversy and has contributed to the polarization between child psychiatry and some family systems approaches to family therapy. Jackson (1965) and Watzlawick et al. (1974) and their colleagues, beginning with the double-bind concept (Bateson et al., 1956), evolved family therapy approaches which view all therapy as a power struggle, which regard inability to change the communication rules within a family as the sine qua non of family systems pathology, and which define the role of the therapist as a change maker who often uses paradoxical directives to force family members out of their inflexible patterns. This focus on change per se rather than on the process by which change is achieved has raised concern among child psychiatrists who point out that change may simply reflect symptom substitution and that sudden, unprepared-for change may lead to an uncontrolled sequence of changes which are harmful to the family. The view of Jackson and Watzlawick and their colleagues regarding therapeutic change, however, may not be so much at odds with dynamic views of therapeutic change as appears on the surface. Skynner (1976), in a thoughtful, if somewhat oversimplified, discussion of the process of corrective experience, observes that therapy is required where an individual's inner models of self and other are maladaptive and not open to testing and correction, or in addition involve distortion of perception and judgment and rigid defensive positions. In attempting to correct maladaptive inner
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models, psychoanalytic methods of therapy rely on the relearning that occurs through the transferenc-v-c-rhe patient's distortions of the therapist are connected with the earlier parental and sibling relationships with whom the models were first developed. For individuals able to repeat and work through these distorted, maladaptive inner models through transfe-r -nce interpretation, these methods lead to effective relearning and substantial therapeutic change. Since psychoanalytic methods require, among other things, a capacity for reasonably accurate symbolic representation of the maladaptive inner models and a reasonable degree of freedom from continual repetition of pathological patterns which reinforce maladaptive inner models in the individual's ongoing life, they are effective and the treatment of choice for some individuals and not others. For other individuals therapies which are more oriented to enactive and iconic modes of cognitive affective organization and do not depend as heavily on a capacity for symbolic representation and which can affect reinforcing pathological patterns directly are more useful. In family therapy one is repeatedly impressed with the power of nonverbal interaction within the family and between the therapist and family members. The affects, attitudes, and behavior of the therapist which are observed and experienced by family members as he reacts and interacts with them are often more important and effective than what he says. This relates to the fact that the genuine response of the therapist, naturally available within him or her and selectively employed in a manner and form called for by the clinical situation, provides a corrective emotional experience for family members. Instead of being inducted, provoked, or stimulated to react or interact as expected, following and repeating the pathological patterns of the family, the therapist provides a different relationship experience which can serve to correct maladaptive inner models. In order to accomplish this the therapist must feel and recognize nonverbal behavioral and role expectations which family members project onto him or her without being taken over by these expectations and acting out a complementary response which would verify rather than correct the maladaptive expectation. In order to accomplish therapeutic change through corrective emotional experience, the therapist must also gently and sympathetically but firmly counter the avoidance mechanisms through which family members resist and turn away from the treatment situation as their anxiety mounts, leaving their expectations untested and uncorrected.
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The concept that therapeutic change involves corrective emotional experience with the model of the therapist provides at least a partial link to the concept of therapeutic change put forward by Jackson and Watzlawick. Jackson and Watzlawick determine that families need therapy when their rules are so inflexible that change cannot occur (the models of interaction are not correctable by reality experience). Paradoxical directives do not simply involve dealing with powerful familial resistance to change by going along with it rather than opposing it head on, but also involve the therapist not complementing the family's expectations, thereby providing a corrective experience. Paradoxical directives either force family members out of their rigid patterns and produce new experience which can correct maladaptive models, or, if they do not follow the directives, make them aware of their avoidance mechanisms. Noting the powerful effects of nonverbal communication and the rapidity with which some parents respond to the corrective model of the therapist's behavior, Skynner (1976) acknowledges that the mechanisms by which this process of change occurs are still obscure. Piaget's cognitive developmental concepts, however, shed some light on the process and provide some explanation for the rapidity with which it can lead to change. In the early sensorimotor and preoperational stages, preschool, and even young school age, children think through concrete experiential modes rather than symbolic representational ones. These earlier modes of cognition, also called enactive and iconic, are not only dominant in early childhood but persist after the stage of formal operations and advanced symbolic representational thought are achieved. The concrete experiential modes of cognitive affective organization are not only developmentally earlier but also closer to a person's feelings, drives, and bodily sensations, and preconscious and unconscious mental activity. Part of the power of nonverbal communication (and the model of the therapist) stems from its enactive and iconic quality. It is more readily received because it is less subject to
monitoring by conscious control and defenses organized around symbolic representation (e.g., intellectualization and rationalization). It "speaks" to those levels of mental activity which are closer to personal-interpersonal conflict and distortion. It conveys messages to the mind and the body in forms most in harmony with the modes of learning of the preschool and early school-age periods of development during which the basic and most influential inner models of self and others are formed. Since these inner models are formed mainly through what is experienced and observed, correc-
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tion of maladaptive models can occur in a more rapid, direct, and holistic manner through observing and experiencing the new and more adaptive model of the therapist.
REFERENCES ACKERMAN, N. w. (1958), The Psychodynamics of Family Life. New York: Basic Books. - - (1966), Treating the Troubled Family. New York: Basic Books. - - - (1972), The growing edge of family therapy. In: Progress in Group and Family Therapy, ed. C. J. Sager & H. S. Kaplan. New York: Brunner/Mazel, pp. 440-456. - - - & BEHRENS, M. L. (1959), The family group and family therapy. In: Progress in Psychotherapy, ed. J. H. Masserman &.J. L. Moreno. New York: Grune & Stratton, 3:63-78. ALEXANDER, F. (1957), Psychoanalysis and Psychotherapy. London: Ruskin House. ANTHONY, E. J. (1973). A working model for family studies. In: The Child and His Family, cd. E. .J. Anthony & C. Koupernik. New York: Wiley, 2:3-20. BATESON, G., JACKSON, D. D., HAl-H, .J., & WEAKLAND, J. H. (1956), Toward a theory of schizophrenia. Behau. Sci., 1:251-264. BEELS, C. & fERBER, A. (1972), What family therapists do. In: The Book of Family Therapy, ed. A. Berber, M. Mendelsohn, & A. Napier. New York: Science House, pp. 168-232. BOSZORMENYI-NAGY, I. (1965), A theory of relationships. In: Intensive Family Therapy, ed. I. Boszormenyi-Nagy & J. Framo. New York: Harper & Row, pp. 33-86. BOWt:N, M. (1966), The use of family therapy in clinical practice. Compreh. Psychiat., 7:345374.
BRODEY, W. M. (1959), Some family operations and schizophrenia. Arch. Gen. Psychiat.. 1:379-402. BROWN, S. L. (1969), Diagnosis, clinical management and 'family interviewing. In: Science and Psychoanalysis, ed.J. H. Masserman. New York: Grune & Stratton, 14:188-198. - - - (1972), Family group therapy. In: Manual of Child Psychopathology, ed. B. B. Wolman. New York: McGraw-Hili, pp. 969-1009. FREUD, A. (1972), The child as a person in his own right. The Psychoanalytic Study of the Child, 27:6214>25. JACKSON, D. D. (1965), The study of the family. Fam. Proms, 4: 1-20. KLEIN, M. (1946), Notes on some schizoid mechanisms. Int.]. Psycho-Anal., 27:99-110. KRAMER, C. H. (1968), Psychoanalytically oriented family therapy. The Family Institute of Chicago (mimeographed). MAHLER, M. S., PINE, F., & BERGMAN, A. (1975), The Psychological Birth of the Human Infant. New York: Basic Books. MALONE, C. A. (1974), Observations on the role of family therapy in child psychiatry training. This Journal, 13:437-458. - - & GISPERT, M. (1977), Divorce and the single parent family. Read at World Congress of Psychiatry, Honolulu, Hawaii. McDERMOTT,.J. F. & CHAR, W. F. (1974), The undeclared war between child psychiatry and family therapy. This Journal, 13:422-436. PAUL, N. L. (1967), The use of empathy in the resolution of grief. Perspectives in Biology & Medicine, II: 153-169. - - - & GROSSER, G. H. (1965), Operational mourning and its role in conjoint family therapy. Comm. Ment. Hlth J: 1:339-345. SANm:R, F. (1973), Freud's, A case of successful treatment by hypnotism. Fam. Process, 13:461-468. SATlR, V. (1964), Conjoint Family Therapy. Palo Alto: Science and Behavior Books. SKYNNER, A. C. R. (1969), Indications and contraindications for conjoint family therapy. Int. ]. Soc. Psychiat., 15:245-250.
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- - - (1976), Systnns of Family and Marital Psychotherapy. New York: Brunner/Mazel. WATZLAWICK. P., WEAKLAND,.J. H., & FISCH, R. (1975). Change. New York: Norton. WILLIAMS, F. S. (1968), Family therapy. In: Modern Psychoanalysis. ed . .J. Marmor. New York: Basic Books. pp. 387-406. WYNNE, L. C. (1965), Some indications and rontraindications for exploratory family therapy. In: Intensive Family Therapy, ed. I. Boszormcnyi-Nagy & .J. Framo. New York: Harper & Row, pp. 289-322. ZIt.BACH,./ . ./ .• BERGH.• E.. & GASS, C. (1972), The role of the young child in family therapy. In: Progress in Group and Family Therapy. ed. C. .J. Sager & H. S. Kaplan. New York: Brunner/Mazcl, pp. 385-399. ZINNER • .J. & SHAPIRO. R. (1972), Projective identification as a mode of perception and behavior in families of adolescents. Int. j. Psscho-Anal., 53:523-529.
Charles A. Malone, M.D.
Abstract. The polarization which has characterized the relationship between child psychiatry
and family therapy no longer dominates the interrelationship between the two fields as it once did. Increasingly child psychiatrists are employing family therapy in their clinical work and discovering the valuable contribution the two fields can make to each other. This paper attempts to explore this fruitful interrelationship by reviewing the usefulness of family therapy in relation to diagnosis, treatment, and crisis intervention and by discussing the role of children and the value of dynamic and developmental concepts in understanding core clinical issues and therapeutic change in family therapy.
Historically, and even currently, there have been considerable conflict and polarization between child psychiatry and family therapy (Brown, 1972; McDermott and Char, 1974). Psychoanalytically oriented child psychiatrists have opposed or resisted family therapy on the grounds that it contaminates the transference or interferes with needed confidentiality in child treatment. They have been concerned about the traumatic effects on children of being explicitly confronted with implicit dangers in their intrafamilial relationships-such as the hostile rejecting feelings of a parent. On the other hand, family therapists (Ackerman, 1966; Kramer, 1968) have been concerned that isolated treatment of the child ignores the sources of the child's disturbance in pathological family patterns, in marital discord, and in the parents' own problems. The sources of this conflict and polarization are multiple. To begin with, there is often a contradiction and fundamental antagonism between family therapy and child psychiatry in that some family therapy theories and techniques implicitly or explicitly ignore individual psychology and psychosexual development, and
Dr. Malone is Professor and Director, Division of Child Psychiatry, Case Western Reserve University School of Medicine and University Hospitals of Cleveland (2040 Abington Road, Cleveland, OH 44106), uihere reprints may be requested.
0002-7138/79/1801-004 $01.51 e 1979 American Academy of Child Psychiatry.
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oppose dynamic principles such as unconscious conflict and motivation. Many family therapy theories conceptualize the symptomatic child as an extension of disturbance in the family system without appreciating the child as a person in his own right (A. Freud, 1972). This is exemplified by family therapy approaches which insist on always seeing the whole family and rule out seeing individual family members, or which focus only on the parents and rarely, or never, include the symptomatic child (Bowen, 1966), even if that child is "very disturbed" (Beels and Ferber, 1972). The various fragmentary, often conflicting, theories of family therapy are difficult to integrate with each other and even more difficult to integrate with analytic meta psychology and developmental concepts. The task of integrating the fragmentary, disparate theories of family therapy with dynamic developmental concepts is complicated by the fact that the process of studying families is extremely difficult. It is difficult to do justice to the complexity and range of family transactions in the process of conceptualization and theory building without risking oversimplification which loses the essence of what transpires in family life. Describing and understanding the reciprocal influence of the intrapsychic developmental needs of individual members and the transactional patterns of the family system are almost insurmountable tasks (Anthony, 1973). The extraordinary complexity of the conceptual task involved, coupled with the pain and frustration of the clinical task of treating serious child, adolescent, adult, marital, and family psychopathology, often leads to defensive disengagement and polarization. Polarization to one theoreticaVconceptual model is usually coupled with intellectualization and rationalization as the merits of one approach versus another are argued, while neither approach is studied and the overwhelming and threatening aspects of severe child and family pathology are avoided and ignored. The polarization between child psychiatry and family therapy reflects in many ways the long-standing internal/external dichotomy and the sterile nature/nurture controversies which have plagued the behavioral sciences. Finally, conflict and polarization between child psychiatry and family therapy have been produced by leaders in each field who foster polemic positions and insist on loyalty from their followers. The considerable overlap between family therapy and child psychiatry is ignored, while differences are emphasized. Thus, some leaders in child psychiatry overgeneralize child analytic techniques to all forms of child treatment and oppose family therapy,
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even though Freud pointed to the importance of family factors in childhood psychopathology (Sander, 1973), and the well-established tradition in child psychiatry of understanding and treating children in relation to their past and current family relationships. Correspondingly some leaders of family therapy use dynamic developmental concepts without acknowledging or even denying any connection to their work. For example, although developing independence through differentiation of the self from the "undifferentiated family ego mass" is central to Bowen's conceptualization of family therapy (1966), he steadfastly avoids relating this clinical process to the separation-individuation process described by Mahler and her colleagues (1975). While the polarization between child psychiatry and family therapy still persists and will continue, it no longer dominates the relationship between the two fields as it once did. Many child psychiatrists and family therapists have been able to move beyond such dichotomous polemics and to take a middle position in which internal and external are seen as inseparable and intrapsychic and interactional forces are viewed as interrelated and interdependent. According to this view, while conflicts which may provide the basis for later pathology arise in the first place in interactions with the demands and prohibitions of the parents, it would be an error to ignore the fact that children interact with parents on the strength of their individual characteristics and innate endowment. Similarly, as Anna Freud (1972, p. 622) observes, "No child should be approached, assessed, treated, nursed, taught, corrected, etc., without taking the parental influences into account, and that without knowledge of their impact neither the child's developmental successes or failures nor his adjustments or maladjustments will be seen in their true light" (my italics). According to this view, psychological development and functioning is a reciprocal intergenerational family process. Families even develop what Anthony (1973) calls "a family likeness" in which members of the same family display the same personality characteristics, coping styles, prejudices, defense mechanisms, and symptom clusters when they fall psychiatrically ill. Increasingly, child psychiatrists have employed family therapy in their clinical work and have applied it to a wide range of issues and tasks. In recent years, the number of child psychiatrists using family interviewing for diagnostic and therapeutic purposes has increased dramatically. Some indication of this growth in interest can be seen in a 1976 survey of over 900 members of the Academy of
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Child Psychiatry which revealed that the majority of those surveyed 1 use family interviews in their clinical work-only 8% never use family interviews for diagnostic purposes and only 12% never use family interviews for treatment purposes. Child psychiatrists doing family therapy have become aware that the knowledge base and clinical skills of child psychiatry play an important and, at times, critical role in their ability to carry out effective family therapy. They have learned that their emphasis on careful diagnosis, knowledge of child development, appreciation of the child's contribution to his own and the family's problems, and ability to utilize the fantasy, play, and verbalizations of children are all crucial to the conduct of family therapy. Family life plays a major role in the development of psychic structure, which in turn shapes family life, through mechanisms such as externalization (Brodey, 1959) and projective identification (Klein, 1946). Object relations theory in particular addresses this issue in its concern with the way in which children internalize their parents as models and how these models influence and are influenced by subsequent relations with significant others in the environment. Dynamically oriented child psychiatrists are keenly aware of the value of psychoanalytic insights in making sense out of the complex data involved in family transactions, in judging the indications or contraindications far family treatment, in devising useful applications of family therapy, in choosing between alternative intervention strategies, and in achieving some degree of order in their thinking about the multiple, diverse, and at times contradictory approaches used in family therapy. In relation to this latter point, Ackerman (1972), in commenting on the diversity of family treatment approaches and the lack of sufficient knowledge regarding family dynamics and diagnosis, bemoaned "the lack of a unified theory in family therapy" and the adverse effects on family therapy of the "preoccupation with experimentation in therapeutic techniques" (p. 445). The field of family therapy is no further along in relation to the development of a unified theory at the present time. Knowledge of family dynamics and diagnosis has to a considerable extent been impeded by the adynamic, adiagnostic quality of many family sysI The survey was responded to by 64 % of the Academy membership with an age. geo· grahical , and practice setting range representative of the Academ y's total membership (Survey Report, Committee on Famil y Therapy, American Academ y of Child Psychiatry, 1976).
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tems approaches. It has also been delayed by the state of our limited knowledge of family development and the range of adjustment that constitutes "healthy" family life. In addition, as indicated earlier, the historic, cumulative, and ongoing interrelationships between intrapsychic and interpersonal forces and how these impact upon and are influenced by the family system are extraordinarily complex. Nevertheless, some of the fragmentation and diversity in regard to family therapy seem unnecessary even with the limitations of our current knowledge. As Ackerman (1972) pointed out, "close scrutiny of contemporary trends in family therapy leads to the impression that the multiple approaches which characterize this field do not in fact represent pure or distinct forms of treatment" (p. 446). There is significant overlap between family therapy approaches and common themes among the concepts utilized to explain these approaches. Exploration of certain aspects of what each field can contribute to the other serves to emphasize the fruitful interrelationship between child psychiatry and family therapy which has been developing in recent years. Since more has been written about the contributions of family therapy to child psychiatry, I will simply review its usefulness in diagnosis and treatment and its applicability to a single clinical task-s-crisis intervention. Since less has been written about the contributions of child psychiatry to family therapy, I will devote more attention to that subject, commenting on the role of children in family therapy and discussing dynamic developmental concepts in relation to core clinical issues and therapeutic change in family therapy. CONTRIBUTIONS OF FAMILY THERAPY TO CHILD PSYCHIATRY
Clinical experience with family therapy increasingly demonstrates its usefulness in diagnosis and treatment and its applicability to a broad range of clinical tasks (Brown, 1969, 1972; Malone, 1974; Skynner, 1969; Williams, 1968). In relation to diagnosis, family interviews enable us to assess how a child's symptoms or dysfunction are influenced by and influence the family system. When family interaction is skillfully facilitated, the presenting problem actually happens in the here and now of the family interview. This provides an opportunity to observe not only family reactions and contributions to the problem, but also the balance of capacity and motivation for or against change in the family as a whole (Skynner, 1969). This enables us to insure the involvement of the psychologi-
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cally relevant family members who collusively or openly are part of and contribute to the problem, or to avoid at the outset an interminable treatment working with only part of the family involved in the problem. While family interviewing helps us to assess a child's general functioning in the family context, it is particularly useful in determining the nonverbal communications which contribute to a child's impulsivity and poor behavioral control, modes of expressing and monitoring affect, overstimulation or understimulation in relation to drives, response to parental demands and prohibitions, defensive and coping processes, identifications, and the quality of his intrafamilial relationships. Family interviewing is particularly helpful in reducing guilt and fear in parents and children, in bolstering self-esteem especially in the identified patient, and in countering loyalty conflicts or secret-keeping that block open communication. Family interviewing enables us to identify the family's characteristic patterns of communication, affect expression, relationship and role, problem solving, and conflict resolution. Finally, family interviews are particularly useful in identifying structural imbalance (scapegoating, splitting, alliances, collusions, symbiotic or sadomasochistic dyads, role reversal, etc.), patterns of projective identification, and underlying marital, parental, and family of origin problems. In relation to treatment, providing one employs a flexible approach (Ackerman, 1958; Malone, 1974) that allows for combining family therapy with individual or marital treatment, concomitantly or in sequence, depending on clinical indications, the usefulness of family interviewing is very broad. Some of the usefulness of family therapy derives from general advantages which it has (Malone, 1974). Family therapy offers more direct therapeutic access to acting-out and symptomatic behavior. It increases the therapist's ability to recognize and counter the secondary gain which the child's symptoms provide for parents, siblings, and the child himself. It increases therapeutic potential by offering a means of identifying and enlisting healthy members or aspects of the family. Finally, it keeps responsibility for problem solving within the family so that, if progress occurs, everyone changes and a new equilibrium is reached (Skynner, 1969). While the indications or contraindications for family therapy in child psychiatric services are still being worked out, clinical experience does suggest useful guidelines. The indications for using family therapy relate closely to the ways in which family interviewing is useful diagnostically. Hence, family therapy is particularly useful in
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treating developmental delays and certain types of presenting problems in children, in modifying relationship and role imbalance, in dealing with un mourned losses or an actual or impending family crisis, in countering scapegoating and the use of a child's symptoms as a conflict-detouring mechanism, in dispelling myths, divisive secret-keeping, and other chronic intrafamilial communication problems, and in working with families dominated by projective identification or where marital, parental, and/or family of origin problems underlie the child's presenting problems (Malone, 1974). In relation to developmental delays, the kinds of problems that may be particularly well suited to or require family treatment are hyperactivity, excessive aggressiveness, failure of urinary or bowel training, severe sibling rivalry, excessive separation anxiety, and failure to develop effective speech (Brown, 1972). Among the presenting problems where family treatment is helpful are: childhood emotional, social, behavioral, and learning disturbances where family interactional patterns contribute to ego or superego dysfunction and/or overstimulation of aggressive or sexual impulses; chronic illnesses with moderate to severe secondary emotional disturbance and developmental interference (such as hemophilia and cystic fibrosis), and psychosomatic illnesses (such as juvenile diabetes, asthma, anorexia nervosa, and functional GI disorders); and children and adolescents who act out ("delinquents" who act out parental impulses or ego-syntonic character disorders), or who have notable separation problems. In addition, because of its general advantages, family therapy is also valuable when combined with individual therapy, in furthering the psychotherapeutic process in relation to children suffering with moderate to severe intrapsychic problems (Malone, 1974). Thus it can be an invaluable aid in the treatment of precisely those problems for which analytically oriented psychotherapy is usually best suited and most effective. In terms of limitations and contraindications, family therapy is not useful when the very process of focusing on family transactions intensifies and perpetuates the pathological patterns within the family without prospects for repair. This is the case in families where one of the parents has severe problems (depression, masochism, paranoia, psychopathy) and is particularly resistant, and the rest of the family cannot become involved in treatment without risking a breakup of the family, which they are unwilling to do. This is also the case where there is a dominance of sadistic gratification and destructive behavior in a family, such as physical and psychological abuse, and there is not enough discomfort to
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motivate the family to change. Similarly, while family interviews and treatment can be very useful in relation to marital separation, family therapy is not indicated and may be harmful when the separated or separating parents have an extremely hostile relationship which is set off by each other's presence. When a firm decision to divorce has been reached, bringing the estranged couple together in family treatment runs counter to their psychological task of separating and relinquishing and working through their ambivalent attachment. Despite this, however, some structured family interviews may be helpful or necessary when the children are being caught in the middle of the divorcing or divorced couples' continuation of their marital battle (Malone and Gispert, 1977). While family therapy is often indicated for adolescents with separation problems, there are times when seeing adolescents with their parents perpetuates rather than counters pathological dependency or symbiotic ties. Similarly, with older adolescents preoccupied with and in the process of disengaging and emancipating from the family, family treatment often runs counter to the adolescent's developmental needs. In relation to the many valuable applications of family therapy to clinical tasks the use of family interviewing and family therapy in ' crisis intervention is a good example. There are many acute, nonrecurrent stresses and crises in the lives of individuals, couples, and families, where several or a series of family interviews are extremely helpful. This brief intervention may lead to family therapy; sometimes, however, family therapy is not possible and may not be indicated. These acute nonrecurrent stresses and crises may involve phases of critical change in family life such as marital separation or transitions such as an adolescent leaving home. They may involve acute, serious physical or mental illness and hospitalization, or life events such as a premature birth or the death of a parent, sibling, or child. Family interviews at such times of crisis enable us to identify the life-style and values uf the family as well as its patterns of relationship and role, communication, affect expression and control, defense, coping and problem solving as these relate to the situational stress. The crisis can be evaluated in terms of the emotional strain on each member, the mobilization of intrapsychic as well as interpersonal problems, and the intrafamilial, extended family, and social network resources available for meeting and resolving the crisis. Family interviews offer an opportunity for members to share information, ventilate feelings, and clarify affective or cognitive confusion or distortion about the event itself.
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This reduces the possibility of acting out guilt and anxiety in provocative behavior and the use of such mechanisms as projection, displacement, and scapegoating. Since these crises involve both actual and threatened losses, a crucial aspect of the clinical work involves the encouragement of a grieving process. Family interviews and family therapy facilitate this process by countering avoidance or the institution of massive defense and by assisting family members to face and master the painful, personal-interpersonal feelings involved. CONTRIBUTIONS OF CHILD PSYCHIATRY TO FAMILY THERAPY
Child psychiatrists who are family therapists have long been aware of the many ways in which their child psychiatric knowledge base and clinical skills are crucial to the conduct of family therapy. At the most fundamental level this involves their ability to include children of all ages and to understand and utilize children's play, fantasy, and verbalizations in family diagnostic and treatment process. The inclusion of children in family therapy has many important ramifications. It is essential to include the "well" siblings. They are needed to point up family problems outside the index patient and thus to counter the devaluation involved for the child labeled as the patient in the family. They may well have problems in their own right and may, in fact, be more disturbed than the index patient. The "well" siblings may be part of a family pattern of scapegoating or be in a parental child role. On the other hand, since the index patient and the parents are usually locked into chronic repetitive patterns, the "well" siblings are often more independent and objective and therefore able to observe and identify family patterns and problems. Younger children in particular are often more direct and open, less defended and "sophisticated," and therefore more apt to express the feelings and conflicts which underlie family transactions. Sometimes siblings serve as a family spokesman in getting to the core interpersonal issues within the family. Including children of various ages has many advantages. The therapist is able to observe the response of family members to children at different stages of development. This contributes valuable information about the difficulties or resourcefulness of parents and children regarding phasic developmental issues. At the same time this offers the therapist opportunities to present models of interaction, communication, and response to children with dif-
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ferent developmental needs which can provide possibilities for corrective emotional experience. The inclusion of young children naturally leads to focusing on play and fantasy and their expressive and defensive use (Skynner, 1976; Zilbach et aI., 1972). Older children bring their experience in the world outside to the family and may be able to "coach" younger siblings in meeting the challenges of school, neighborhood, or peer group. The value of child psychiatric knowledge goes well beyond the ability to understand and utilize the role of children in family therapy, however. The dynamic developmental orientation of child psychiatry has implications in relation to understanding and treating core clinical issues that repeatedly appear in family transactional process and in relation to understanding aspects of the therapeutic change which occurs in family treatment. Dynamic Developmental Concepts in Relation to Core Clinical Issues in Family Therapy
A ubiquitous theme in the conceptualizations of many leading figures in the field of family therapy (Bell, Bowen, Brown, Kramer, Nagy, and Paul), regardless of their theoretical orientation, involves the various ways parents can carryover unresolved conflicts and losses, organizing views of self and others, identifications and roles from their family of origin into their nuclear family life. These ghosts from the past affect or dominate marital choice, the character of the marriage, parental functioning, and parent-child and family interaction. All those who do family therapy are familiar with the clinical process of starting with the family's focus on one child who is symptomatic and working back through the complex network of projections, displacements, and identifications, to the parental, marital, personal, and family of origin problems which underlie the family's initial concerns. As a part of this clinical process the therapist brings to the family's awareness complementary patterns involving projective identification (Wynne, 1965; Zinner and Shapiro, 1972), in which an unwanted part of one parent is projected onto and identified in a spouse or a child who in turn develops attitudes and behaviors which complement the projection. This mechanism operates in a similar fashion to reciprocal role expectations and serves to keep intolerable qualities, ideas, and feelings out of awareness while retaining these qualities, ideas, and feelings within view at a psychologically safe distance. This mechanism usually leads to a powerful collusive interdependent system of forces in the family. Depending on their extent and
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chronicity, these complemental interlocking patterns of projective identification interfere with undifferentiated independent functioning of famil y members and create varying degrees of individual and interpersonal problems and of pathological family enmeshment and lack of differentiation with concomitant problems related to separation anxiety . With individual variations, many family therapists conceptualize their approach to family therapy in terms of assisting family members to break pathological symbiotic and dependency ties and to separate and differentiate themselves from famil y enmeshment in order to achieve effective independent functioning. Thus Ackerman and Behrens (1959) speak of separation and differentiation from the parental matrix, while Bowen (1966) emphasizes the process of differentiation of spouses from each other and a pathologically dependent symbioticlike "emotional oneness." Satir (1964), while she presents herself to families as an expert in and teacher of communication, is also committed to helping each family member experience "individuation." Boszormenyi-Nagy (1965), who has developed perhaps the most ambitious integration of obj ect relations theory, ego psychology, and transactional process, has as a corne rsto ne of his approach the uncovering of distorted partobject introjections and projections of parents within the nuclear family. Finally, Paul (1967) and Paul and Grosser (1965) explicitly organize family treatment as a process designed to exorcise the ghosts from the family of origin which dominate the life of the nuclear family. Paul attempts to uncover the effects of the unrelinquished object, usually an un mourned loss of a parent or sibling, on cu r re n t famil y life and to ca rry out a process of mourning and relinquishing. Interestingly, in this process the therapist presents himself as a model of empathy which is a healthy form of projective identification and also utilizes nonverbal communication and role modeling. These conceptualizations of the process of family treatment explicitly or implicitly lean heavily on object relations theory and the separation-individuation developmental process. Where parems carryover attachments, conflicts, and unresolved losses, organizing images of self and other, identifications, and roles from their family of origin, they are expressing ideas, feelings, fantasies, behaviors, and models experienced, learned, and internalized in childhood . Such parents , at least in specific areas related to the unrelinquished ties and/or unresolved conflicts with parental objects, have not achieved a full degree of separation and individua-
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tion from their own parents. The more incomplete the separation process, the more dependent and undifferentiated or symbiotic that parent's object relations will be and the more he or she will rely on projection, introjection, and splitting mechanisms. Object relations theory concerns itself with the way children internalize their experience with their parents and significant others, forming an inner world of self and other object representations which serve as models for current and future behavior in relation to the parents or other authority figures and for role functioning in later life. The separation-individuation process is intertwined and interrelated with the process of internalization of self and other object representations (Mahler et al., 1975). When individuals achieve full autonomy they not only have successfully internalized stable differentiated models of self and others which can be modified or corrected by experience, but they also have achieved a degree of independence and conflict-free functioning which enables them to meet new situations and people without necessarily having to repeat their inner models. When separationindividuation is incomplete, the individual cannot differentiate himself sufficiently from his inner models and tends, or is compelled, to repeat them. In addition, the models internalized include maladaptive and pathological relationship experiences with parents and significant others which usually are not modified or corrected by experience. This ultimately sets the stage for the kinds ofinadequately differentiated maladaptive personal-interpersonal motivations, behaviors, defenses, and relationships that profoundly affect marital choice, marriage, parental functioning, and family life and which so frequently are and have been the focus of family therapy. In relation to the therapeutic issues involved in attempting to assist families to resolve maladaptive object relations related to developmental deficits in the separation-individuation process, Bowen (1966) observes that with certain families where differentiation of the marital couple is not possible, he is willing to work with the healthier spouse. However, he cautions that if the work is successful and the treated spouse is able to differentiate, he or she must be prepared for distressing reactions in his or her mate. The most profoundly threatening of these reactions involves withdrawal with the implicit or explicit concomitant threat of separation. In response to this the treated spouse is likely to get depressed, confused, and develop a whole spectrum of physical symptoms. As Bowen puts it (1966, p. 189), "this is the reaction of one's psyche
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Charles A. Malone
and soma as it cries out for the old dependence and togetherness." In order to maintain the change achieved and evolve a new balance in the marriage, the treated spouse must be able to tolerate the depressive affect and anxiety engendered by the threatened loss of attachment implicit in the mate's strong resistance to the change and reaction of withdrawal. Brown (1969) places these issues into a broader perspective which includes children. He notes that patterns of interpersonal relationship in families often protect inner models from being al-. tered by real events. Therefore significant change in family members and intrafamilial relationships produces or threatens to produce a partial internal loss (relinquishing of internal self and other object representations or models) and is resisted and/or reacted to with separation anxiety and grief. Thus, change in a wife engenders anxiety in a husband which may lead to a new surge of overinvolvement with the symptomatic child, who also reacts to the change in his mother as an actual or threatened loss and may temporarily regress and become more infantile and demanding, which in turn reinforces and is reinforced by the father's overinvolvement. These events in turn exert a strong pull on the wife/ mother to return to her old patterns. Family therapists must anticipate and be prepared to help family members recognize resistance to change and work through threatened and actual object relationship losses which are inevitably associated with significant change in family members and intrafamilial relationships, or else the change will not last or will not be beneficial to the family. Thus, whatever language he frames his understanding in, the family therapist who intends to help a symptomatic child by removing the influence of underlying marital, parental, or family of origin problems must appreciate the psychology of attachment, separation, and loss, the relationship between inner models and external intrafamilial relationships (in both parents and children), and that resistance to change involves not only a counterreaction to a shift in the family homeostasis, but expectable psychological responses to threatened and actual object and part object loss. Dynamic Developmental Concepts in Relation to Therapeutic Change in Family Therapy
Corrective emotional and object relationship experience (Alexander, 1957) has long been recognized as being significant in psychotherapeutic change in both adults and children. Child psychiatrists who are family therapists have frequently pointed to
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the significant advantage of family therapy in relation to corrective emotional experience in work with children (Williams, 1968). In individual therapy children often reproduce aspects or essential qualities of their troubled or pathological relationship with a parent. They project their inner models of self and parent onto the therapist and the interaction with him or her. Although the therapist may attempt to correct the child's view and experience of himself by not following the projected model and behaving and relating differently from the parent, such corrective experiences may be negated or undermined by the child's continuing intrafamilial experience with the parent and other family members. Family therapy offers not only a means of countering the undoing of corrective emotional experience, but, more importantly, of producing actual change in the parents (often through their own corrective experience and identification with the model of the therapist). Thus, the model of parent-child interaction changes, directly producing a much more powerful corrective emotional experience. This leads to a consideration of the subject of therapeutic change which is the focus of considerable controversy and has contributed to the polarization between child psychiatry and some family systems approaches to family therapy. Jackson (1965) and Watzlawick et al. (1974) and their colleagues, beginning with the double-bind concept (Bateson et al., 1956), evolved family therapy approaches which view all therapy as a power struggle, which regard inability to change the communication rules within a family as the sine qua non of family systems pathology, and which define the role of the therapist as a change maker who often uses paradoxical directives to force family members out of their inflexible patterns. This focus on change per se rather than on the process by which change is achieved has raised concern among child psychiatrists who point out that change may simply reflect symptom substitution and that sudden, unprepared-for change may lead to an uncontrolled sequence of changes which are harmful to the family. The view of Jackson and Watzlawick and their colleagues regarding therapeutic change, however, may not be so much at odds with dynamic views of therapeutic change as appears on the surface. Skynner (1976), in a thoughtful, if somewhat oversimplified, discussion of the process of corrective experience, observes that therapy is required where an individual's inner models of self and other are maladaptive and not open to testing and correction, or in addition involve distortion of perception and judgment and rigid defensive positions. In attempting to correct maladaptive inner
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models, psychoanalytic methods of therapy rely on the relearning that occurs through the transferenc-v-c-rhe patient's distortions of the therapist are connected with the earlier parental and sibling relationships with whom the models were first developed. For individuals able to repeat and work through these distorted, maladaptive inner models through transfe-r -nce interpretation, these methods lead to effective relearning and substantial therapeutic change. Since psychoanalytic methods require, among other things, a capacity for reasonably accurate symbolic representation of the maladaptive inner models and a reasonable degree of freedom from continual repetition of pathological patterns which reinforce maladaptive inner models in the individual's ongoing life, they are effective and the treatment of choice for some individuals and not others. For other individuals therapies which are more oriented to enactive and iconic modes of cognitive affective organization and do not depend as heavily on a capacity for symbolic representation and which can affect reinforcing pathological patterns directly are more useful. In family therapy one is repeatedly impressed with the power of nonverbal interaction within the family and between the therapist and family members. The affects, attitudes, and behavior of the therapist which are observed and experienced by family members as he reacts and interacts with them are often more important and effective than what he says. This relates to the fact that the genuine response of the therapist, naturally available within him or her and selectively employed in a manner and form called for by the clinical situation, provides a corrective emotional experience for family members. Instead of being inducted, provoked, or stimulated to react or interact as expected, following and repeating the pathological patterns of the family, the therapist provides a different relationship experience which can serve to correct maladaptive inner models. In order to accomplish this the therapist must feel and recognize nonverbal behavioral and role expectations which family members project onto him or her without being taken over by these expectations and acting out a complementary response which would verify rather than correct the maladaptive expectation. In order to accomplish therapeutic change through corrective emotional experience, the therapist must also gently and sympathetically but firmly counter the avoidance mechanisms through which family members resist and turn away from the treatment situation as their anxiety mounts, leaving their expectations untested and uncorrected.
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The concept that therapeutic change involves corrective emotional experience with the model of the therapist provides at least a partial link to the concept of therapeutic change put forward by Jackson and Watzlawick. Jackson and Watzlawick determine that families need therapy when their rules are so inflexible that change cannot occur (the models of interaction are not correctable by reality experience). Paradoxical directives do not simply involve dealing with powerful familial resistance to change by going along with it rather than opposing it head on, but also involve the therapist not complementing the family's expectations, thereby providing a corrective experience. Paradoxical directives either force family members out of their rigid patterns and produce new experience which can correct maladaptive models, or, if they do not follow the directives, make them aware of their avoidance mechanisms. Noting the powerful effects of nonverbal communication and the rapidity with which some parents respond to the corrective model of the therapist's behavior, Skynner (1976) acknowledges that the mechanisms by which this process of change occurs are still obscure. Piaget's cognitive developmental concepts, however, shed some light on the process and provide some explanation for the rapidity with which it can lead to change. In the early sensorimotor and preoperational stages, preschool, and even young school age, children think through concrete experiential modes rather than symbolic representational ones. These earlier modes of cognition, also called enactive and iconic, are not only dominant in early childhood but persist after the stage of formal operations and advanced symbolic representational thought are achieved. The concrete experiential modes of cognitive affective organization are not only developmentally earlier but also closer to a person's feelings, drives, and bodily sensations, and preconscious and unconscious mental activity. Part of the power of nonverbal communication (and the model of the therapist) stems from its enactive and iconic quality. It is more readily received because it is less subject to
monitoring by conscious control and defenses organized around symbolic representation (e.g., intellectualization and rationalization). It "speaks" to those levels of mental activity which are closer to personal-interpersonal conflict and distortion. It conveys messages to the mind and the body in forms most in harmony with the modes of learning of the preschool and early school-age periods of development during which the basic and most influential inner models of self and others are formed. Since these inner models are formed mainly through what is experienced and observed, correc-
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tion of maladaptive models can occur in a more rapid, direct, and holistic manner through observing and experiencing the new and more adaptive model of the therapist.
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BRODEY, W. M. (1959), Some family operations and schizophrenia. Arch. Gen. Psychiat.. 1:379-402. BROWN, S. L. (1969), Diagnosis, clinical management and 'family interviewing. In: Science and Psychoanalysis, ed.J. H. Masserman. New York: Grune & Stratton, 14:188-198. - - - (1972), Family group therapy. In: Manual of Child Psychopathology, ed. B. B. Wolman. New York: McGraw-Hili, pp. 969-1009. FREUD, A. (1972), The child as a person in his own right. The Psychoanalytic Study of the Child, 27:6214>25. JACKSON, D. D. (1965), The study of the family. Fam. Proms, 4: 1-20. KLEIN, M. (1946), Notes on some schizoid mechanisms. Int.]. Psycho-Anal., 27:99-110. KRAMER, C. H. (1968), Psychoanalytically oriented family therapy. The Family Institute of Chicago (mimeographed). MAHLER, M. S., PINE, F., & BERGMAN, A. (1975), The Psychological Birth of the Human Infant. New York: Basic Books. MALONE, C. A. (1974), Observations on the role of family therapy in child psychiatry training. This Journal, 13:437-458. - - & GISPERT, M. (1977), Divorce and the single parent family. Read at World Congress of Psychiatry, Honolulu, Hawaii. McDERMOTT,.J. F. & CHAR, W. F. (1974), The undeclared war between child psychiatry and family therapy. This Journal, 13:422-436. PAUL, N. L. (1967), The use of empathy in the resolution of grief. Perspectives in Biology & Medicine, II: 153-169. - - - & GROSSER, G. H. (1965), Operational mourning and its role in conjoint family therapy. Comm. Ment. Hlth J: 1:339-345. SANm:R, F. (1973), Freud's, A case of successful treatment by hypnotism. Fam. Process, 13:461-468. SATlR, V. (1964), Conjoint Family Therapy. Palo Alto: Science and Behavior Books. SKYNNER, A. C. R. (1969), Indications and contraindications for conjoint family therapy. Int. ]. Soc. Psychiat., 15:245-250.
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- - - (1976), Systnns of Family and Marital Psychotherapy. New York: Brunner/Mazel. WATZLAWICK. P., WEAKLAND,.J. H., & FISCH, R. (1975). Change. New York: Norton. WILLIAMS, F. S. (1968), Family therapy. In: Modern Psychoanalysis. ed . .J. Marmor. New York: Basic Books. pp. 387-406. WYNNE, L. C. (1965), Some indications and rontraindications for exploratory family therapy. In: Intensive Family Therapy, ed. I. Boszormcnyi-Nagy & .J. Framo. New York: Harper & Row, pp. 289-322. ZIt.BACH,./ . ./ .• BERGH.• E.. & GASS, C. (1972), The role of the young child in family therapy. In: Progress in Group and Family Therapy. ed. C. .J. Sager & H. S. Kaplan. New York: Brunner/Mazcl, pp. 385-399. ZINNER • .J. & SHAPIRO. R. (1972), Projective identification as a mode of perception and behavior in families of adolescents. Int. j. Psscho-Anal., 53:523-529.
