Community Mental Health Journal Volume 2, Number 1, Spring, 1966
CRISIS
INTERVENTION
AND
SOCIAL
WORK
MODELS
ROBERT A. PORTER, M.S.S.W.*
Crisis theory is discussed in relation to a mental health consultation project with visiting teachers. Case illustrations of preventive intervention are offered, and characteristics of cases which best lend themselves to this type of intervention are delineated. The adaptability of the supervisory model in social work to the consultation task is demonstrated. Caplan's theory of the theme interference type of consultee-eentered case consultation is illustrated in the visiting teacher project.
The increasing use of crisis intervention in social agency practice can be combined effectively with concepts of mental health consultation to form strategic preventive programs in community mental health. This paper will discuss crisis theory in relation to a mental health consultation project with visiting teachers and the adaptability of the supervisory model in social work to the consultation task. CONCEPT OF CRISIS The individual, in the course of his life span, experiences a number of developmental and accidental crises, which we
have come to know in clinical practice as the precipitating stresses leading to emotional disorder or mental illness. The developmental crises relate to such episodes as the child's first leaving home to attend school, biological changes at puberty, the establishment of an independent existence away from the parental home, marriage, childbearing, old age, and death. The accidental crises include such matters as separation and divorce, abandonment, pregnancy out of wedlock, unemployment, etc. --problems characteristically presented to social agencies. In these critical moments, the manner in which the individual copes with, or is helped to cope with, the stress
*Mr. Porter, a social worker, is Assistant Professor, and Director of Social Service, Department of Psychiatry, Emory University, School of Medicine, Atlanta, Georgia. 13
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THE 'COMMUNITY MENTAL HEALTH JOURNAL
may have far reaching consequences for his future mental health as well as that of other persons who may be caught in the problem network with him. At these times, when he is struggling to find some resolution and when his coping system is still open and fluid, he may achieve mastery of the problem without future restriction to his personality; he may compromise with the situation and find some sort of adjustment; or he may use regressive devices which will be detrimental to his future mental health. Under the emotional impact of the crisis the individual, still in the throes of problem solving, and not yet settled (or perhaps only tentatively settled) on a coping system, is more receptive to help and more subject to influence than he is once a coping system has evolved and become crystallized. Professional intervention at this point, by aiding the individual to adopt reality-based adjustive or adaptive devices, will usually yield maximum results for minimum efforts. If one succeeds in helping the individual to choose an effective coping system, it is fair to say that he has accomplished a bit of preventive psychiatry in that he has helped the individual to avert psychopathological sequelae which would result from maladaptive or maladjustive patterns. Now it is usually assumed in clinical practice that the defensive or coping pattern, which the individual uses when confronted with significant stress, is determined by predisposing factors in the individual personality. Epidemiological research done in recent years by community psychiatrists, however, call this assumption into question. These studies have concluded that the vulnerability of the individual to neurotic resolution in a crisis situation is more significantly related to factors in the social system in which the crisis occurs than to predisposing factors in the personality. For instance, Caplan (1964) cited a study done in the late 50's by a group of military psychiatrists, oriented in community psychiatry, which bears on this point. These psychiatrists have emphasized the significance for the onset and continuation of mental
disorder in a soldier of the emotional milieu of the military unit of which he is a member. Glass (1959) has shown that epidemiological data indicate that the incidence of "combat neurosis" is related to the circumstances of the combat situation rather than to previously existing personality factors in the individual exposed to stress. These situational circumstances relate to the intensity and duration of the battle, but more significantly to the degree of support given the individual by buddies, group cohesiveness, and leaders. Moreover, he showed that the defensive patterns adopted by individuals in the face of stress are molded by the social pressures of the group. [p. 141 A related study done in England by Brown (1959) concluded that the prognosis for the discharged psychiatric patient is more significantly related to factors in the social environment to which the patient returns than to the clinical diagnosis. Such studies as these stimulate a great deal of reflection regarding possibilities for preventive concepts in mental health in agency programming and administration, leadership roles, group process, social action, and community organization. Our society is equipped with a great many health, welfare, social, religious, legal, and other institutions which have direct and immediate contact with individuals in crisis situations. Mental health consultation with the caretakers who operate these institutional programs can be an effective means of preventive psychiatry. Case Illustrations
Two case illustrations of crisis intervention, selected from a group consultation project with visiting teachers, will be presented. These cases, along with similar ones not here discussed, will be used as the basis for inferring some generalizations about the characteristics of cases which best lend themselves to crisis intervention. .4 Case o] "School Phobia." A visiting teacher brought in a case of a ten-year-old, fourth grade girl, an only child, who had refused to attend school for two successive weeks at the point of referral. She was a somewhat retiring, timid little girl with tentative speech. She had good intelligence and had performed quite well academically. She was presenting the initial symptoms of the so-called "school phobia."
ROBERT A. PORTER
15
It was significant that the father accompanied the father's resumption of his occupational role. the child to the interview. The mother worked and The visiting teacher, in view of her particular was unable to attend. An examination of the knowledge and skills, was not encouraged to delve child's relationships with the significant persons in deeper into it. her life revealed nothing to account for her sympIt is tempting to speculate what might have toms. Exploration of the father's current adjusthappened had this child been placed on a six ment, however, immediately yielded clinically sigmonths' waiting list at some child guidance clinic. nificant material. He had had a heart attack in Probably the maladjustive pattern in both father recent months, had become preoccupied with and child would have become so sufficiently set or fears of another such attack, and had developed so fixed that it would y i d d only to extensive considerable anxiety about death. He had been a psychotherapeutie intervention. Meantime, the mechanic for many years, but had given up his secondary complications of both a psychic and job in favor of doing farm work on the small social nature would have made the therapeutic acreage where he lived so that he might be close task a more complex and belabored one. The to home in the event of another heart attack. His eventual interdisciplinary diagnostic study, six wife, of course, was not at home during the day. months removed from the onset of the problem, As the father revealed his fears and anxieties would probably find the isolation and identificaabout himself, the child indicated that she was tion of the precipitating stress more difficult. Of fully aware of them. She acknowledged and could course, if the case had been admitted to outtalk about her fear that her father might die patient treatment at a later date, both father and while she was away at school. The father had child may well have had their other problems effectively communicated to the child his need for attended to. Preventive psychiatry, however, is her to remain at home as a symbol of security and aimed primarily at the prevention of mental illprotection for himself in the event of the feared ness and incapacitating emotional disorder, and catastrophe, yet he was consciously quite amazed cannot aspire, at this stage of our knowledge, if to learn of the burden which his anxiety about ever, to making maximally healthy persons out himself had imposed on the child. He was enof all human beings. couraged to seek medical assessment of his heart .4 Case o/Rebellion. The second case concerns condition so that he might gain a realistic pera 14-year-old Negro girl who was referred for speetive of the limitations it imposed. The following week the visiting teacher reported that the recent school failure, truancy, and sexually actingfather had returned to his earlier job as auto out behavior. At home the girl had become passively rebellious and difficult to deal with. The mechanic and that the ehild had returned to school became alarmed when the girl was disschool. A follow-up investigation a year later recovered nude in an apartment near the school vealed that the child had had no further recurfence of the school phobia. with a group of teen-agers. The girl was referred While one might attribute the dramatic results last November and had been presenting diffieuhy in this case to a good bit of luck, a closer analysis since the beginning of the school term. Previously her academic achievement was good and she had of the circumstances of the ease offers a more gotten along quite well at home and at school. She satisfying explanation. Most importantly, the ease was detected early and referred promptly by the appeared for the interview with her grandmother visiting teacher. One can only eonelude, judging who had raised her from infancy. The child was from the change in both father and child, that born out-of-wedlock and her natural mother had the maladjustive coping system which both had moved to the midwest soon after her birth. The been using had not yet become firmly crystallized. grandmother was a lower middle class woman with Focusing the anxiety for both father and child strong middle class moral values. She was a little and discussing, mostly by implication, the negative rigid but quite maternal, adequate, mature, and giving. No headway was made in understanding consequences for both of the maladjustive patterns they were using to cope with this anxiety the girl's behavior until she was questioned about was apparently all that was needed to motivate her natural mother. This proved to be a highly them to use a healthier pattern. No treatment sensitive area; she disselved into tears when it was used, certainly not in the usual psychothera- was suggested that she missed her mother very peutie sense, and neither father nor child was much. She then revealed that her natural mother pushed into a patient role. Neither the father's had visited her three months previously, for the depression and self-destructive impulses nor the first time in five years, and on departing had child's generally inhibited demeanor went unobpromised to send the girl bus fare so that she served clinically. However, the father did not might visit the mother in the midwest Meanwhile, present himself as a eandidate for psychotherapy, the girl's older brother, who had also been raised and one did not want to demoralize him by sugby the grandmother, did visit the natural mother gesting it, unless his subsequent behavior, as and returned to report that the mother continued observed by the visiting teacher, should indicate to be as promiscuous as the grandmother had that this step should be taken. Resolution of the difficulty was achieved at the social problem level, known her to be in earlier years. The grandmother, feeling the mother would he a bad influence, namely, by the child's return to school and by
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THE 'COMMUNITYMENTAL HEALTH JOURNAL
thereupon refused to let the girl visit her mother. It was from this point that the girl's difficult behavior began to develop. In the interview it became apparent that the girl had idealized her absent mother and refused to believe the negative reports about her. She was quite depressed in the interview, did little talking, and cried most of the time. The grandmother had made no connection between the earlier conflict situation and the girl's current behavior difficulties. She accepted the connection which was made for her, was able to identify with the girl's sense of loss and anger, and accepted the suggestion that she let the girl visit the mother. I felt safe in making this suggestion for two reasons: (a) a continuation of the girl's current behavior pattern could only lead to a worsening of the situation and to a fulfillment of the grandmother's fears; and (b), the rather adequate nurturance of this child by her grandmother throughout her earlier life made it unlikely that she would be susceptible to negative influence from the mother. The grandmother w~s given considerable support in this regard. The visiting teacher subsequently reported that the child had returned to school; and six months later, there has been no further evidence of truancy or of promiscuous behavior. She is achieving academically at her earlier level. I later had occasion to see the grandmother a second time, and learned that she had promised to let the girl visit her mother at the end of the school year and that they had talked out many of their feelings about their earlier conflict. Again, it is interesting to consider what might have happened to the girl had her problem behavior continued for another six months. If the grandmother had been more adequate to the child's needs at this strategic moment in her life, would the maladjustive behavior have developed at all? Was the girl's choice of behavioral response determined primarily by predisposing factors in her personality, or was it a socially prescribed pattern adopted from her peers who were involved in the same behavior? It should be emphasized that the intervening activities on my part were primarily directed toward the grandmother rather than the girl.
Some Generalizations A few generalizations regarding the characteristics of those cases which most readily lend themselves to this kind of preventive intervention can be made: 1. The onset of the psychosocial problem is usually clear cut, often even dramatic. 2. The level of adjustment prior to the crisis situation, although it may have been neurotic, is stable in the homeostatic sense.
3. Judging from the fact that the focal anxieties are easily elicited, and that the change in behavior subsequent to intervention m a y be as dramatic as the change in behavior following the crisis situation, one must conclude that the emergency-coping pattern used by the individual is not yet fixed. Or, put in terms of the theory of neurosis, we might say that the adjustment reaction is largely situational and has not yet been firmly internalized. This might be contrasted with the chronically neurotic or character disordered personality where the repressive forces are so strongly entrenched that anxiety ~s firmly bound by a variety of defenses, especially denial, displacement, etc. 4. The nascent state of the adjustment reaction, characterized by high anxiety levels, and the exigencies of the crisis situation, usually characterized by considerable social pressures, engenders a dependency in the client which makes him most susceptible to influence. Once the crisis has passed and the maladjustive behavior pattern is fixed, motivation for help may be proportionately reduced. 5. The crisis situation does not seem to be a one person phenomenon. The crisis is usually generated out of an intimate, interpersonal complex. In case work, of course, we look closely at the social role relationships, which are always reciprocal, and for interruptions in complementary nurturance. Breakdown in the one part always has repercussions for the reciprocal part. ner or partners. 6. The parties involved in the crisis situation obviously have a knowledge of the social problem or behavioral difficulty for which they seek help. Investigation will reveal that they also have a conscious knowledge of the precipitating conflict or stress, but that they usually do not make a connection between the two. 7. Treatment of the crisis situation typically involves the identification and focusing of the anxiety, the relating of this to the precipitating stress or conflict, the yen-
ROBERT A. PORTER tilation and communication among the parties of the dormant feelings about the conflict or stress situation, and the interjection by the therapist of his corrective reality-based observations and judgments which permit the client to find a more adaptive method of problem solution. Investigation of the crisis situation or problem behavior generally does not need to exceed the bounds of the current life situation. Examination of current social role relationships and environmental influence will usually yield the genetic data which will account for the crisis situation and the emergency behavior. Exploration of early life experiences, while perhaps enlightening, yields little or no data of relevance to the treatment task. Character structure can usually be adequately discerned in the current context. Anxiety is identified as it fulminates when sensitive areas are touched. This task is made easy by the fact that the anxiety is as yet poorly defended against. It is not usually met vigorously with denim or other defensive maneuvers. As the parties ventilate the impounded affect surrounding the conflict or stress situation, with encouragement from the therapist, anxiety levels are lowered and corrective adjustments tend to be made. The interjection by the therapist of his reality-based observations and judgments aid in this process. The impounded affect is almost entirely contained at preconscious levels. The social pressure implicit in the visiting teacher's follow-up contacts, along with the support he offers, constitutes an important contribution to the client's sustained efforts at problem solution. 8. Preventive intervention may focus more treatment actively on collaterals in the social system network of the primary client than on the client himself. This would, of course, be consistent with the research findings of the community psychiatrists, quoted above, to the effect that susceptibility of the individual to neurotic resolution or other maladaptive response to crisis appears to be more significantly related to inadequate nurturance in the social milieu than to predisposing factors in the personality. In the case of the school phobic
17
girl, it would certainly appear that the father's return to work, for all the shifting in his psychic economy which that act represented, was the crucial factor which released the child from the burden of anxiety which kept her from attending school. And in the second case of the actingout teen-ager, it would seem that the relaxation of the rigidity in the grandmother was the principal factor which permitted the child to resume her earlier pattern of stable adjustment. We might look at the matter another way by asking, in reference to the first case, whether the little girl would ever have developed the school phobia had the father not become so anxious about his own health; or, in the second case, whether we would ever have come t o know the teen-age girl if her grandmother had been more understanding of the child's needs when she was confronted with the brutal facts about her natural mother. 9. Early detection and referral are crucial to the success of this type of preventive intervention. The location of the mental health consultant in an institutional program such as the public school system permits maximum exploitation of opportunities for preventive treatment. 10. This kind of preventive intervention requires a considerable amount of activity on the part of the consultant. The professional passivity of analytically-oriented psychotherapy will not work in these kinds of situations. The initial or exploratory phase of the interview, where one is attempting to identify the anxiety and establish its cause, may move more in the traditionally passive approach. However, once this information is established, effective intervention requires a fairly active playback by the consultant of his assessment in a fashion appropriate to the vernacular and level of understanding of the client. The cases on which these generalizations are based are fairly simple ones, if any behavior can be said to be simple, in the sense that the psychodynamic formulation is fairly easily established, and the client is easily susceptible to remedial or reparative influence. However, it is probable that
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THE COMMUNITYMENTAL HEALTH JOURNAL
more complex cases, if approached with the same spirit of preventive intervention, will yield to attempts at classification and the development of modifications of this approach appropriate to the differing levels of complexity of the cases studied. CONSULTEE-CENTERED CASE CONSULTATION So far the discussion has been directed toward client-centered case consultations in crisis intervention. The topic now will shift to a type of mental health consultation which focuses on the alleviation in the consultee of countertransference phenomena which obstruct his efficient and objective treatment of the client. This kind of consultation can be readily adapted from the supervisory model in social work. The client is not seen by the consultant, and the process focuses entirely around the case material presented by the consultee. A brief outline of the supervisory model in social work will be described as this relates to the emerging body of consultation theory in community psychiatry and will be followed by an illustration of this type of consultation in my visiting teacher group using Caplan's (1964) concept of the theme interference, reduction type of consultee-centered, case consultation.
The Supervision Model Social work supervision is somewhat different from its counterpart in psychiatry. The learner in any of the mental health disciplines will inevitably find that certain unresolved problems in his own personality will at times interfere with the efficiency of his efforts to help his client or patient. Psychiatry typically handles this problem by encouraging the resident to seek some type of psychotherapeutic experience as a part of his training program. Psychiatric supervision, therefore, remains primarily patient centered. That is, the supervisor addresses his efforts primarily to helping the resident understand the complexities of diagnosis and treatment with reference to his patient. Social work, on the other hand, cannot generally rely on a formal thera-
peutic experience as a safety valve or control over the patient needs of the social work student, and has had to build into its supervisory process a device for dealing with countertransference in the learner. Although this is not a psychotherapeutic device, psychic change in the learner is achieved. Supervision in social work is largely learner centered, rather than client centered, and we establish an educational diagnosis of each student which prescribes the nature of much of our supervisory task. The educational diagnosis is largely an assessment of the student's capacities and learning blocks. For instance, interruption of the learning process in the student may be indicated by undue resistance to the supervisor as the student struggles to shift his loyalties from past mentors with a different theoretical frame of reference to present ones, or by regressive behavior as he demonstrates that his intellectual grasp of theoretical considerations is quite in advance of his development of skills to implement his knowledge. Not infrequently, however, the learning task may be interfered with by the intrusion of a countertransference phenomenon, evoked by the life situation or problem of the client, so that the student becomes unable to perceive his client realistically or to offer him effective help. For instance, a student in a child protective agency may be assigned a case in which he must explore evidence of alleged parental neglect in a mother who apparently failed to make adequate provision for supervision of her children in her absence while working. Following his interview of the mother, the student reports to his supervisor an array of evidence to demonstrate that the mother is indeed quite neglectful and concludes that the child should be taken from her. He is somewhat emotional in his presentation, perhaps even moralistic or punitive in his attitude toward the mother. While he may report some evidence of the mother's adequacy, he assesses it lightly, and shows little understanding of the mother's anxieties and little or no disposition to help her. The clue to the student's countertransference problem lies in his overidentification
ROBERT A. PORTER with the victimized child, with his stereotyped perception of the mother, and with his distorted or skewed data collection. Or the student in a family service agency, working with the depressed wife of a man who is threatening divorce, may feel that he must save the marriage at all costs and adopts the same hostile attitudes toward the husband as his client. The wise supervisor will not direct the student's attention to unresolved problems in himself as this would not only increase his anxiety and invite resistance, but also convert the supervisory hour into a therapeutic session with the student. Instead, he will keep the discussion on the client's problem situation and emphasize evidence in the case which will serve to counteract the student's distorted or stereotyped perception of the client. In the first illustration above, he might invite a discussion of the mother's anxieties and needs, or point to evidence of the mother's adequacy. The supervisor's essential aim is to loosen the student's neurotic perception and to hold out the prospect of a reality-based resolution. In a sense, this is the essential goal of the psychotherapeutic encounter, though it is unlike it in that the therapeutic message is mediated indirectly through a discussion of the client's, rather than the student's, problem. The validity of this technique is demonstrated only as the student is freed to help his client, or by his demonstration in subsequent but similar cases that he is able to perceive his client more objectively. Note particularly, in this supervisory model, that it is not necessary for the supervisor to explore the life history material in the student that would explain or account for the countertransference phenomenon; in fact, such a procedure is definitely contra-indicated. Even if the student voluntarily injects anamnestic material into the discussion, it is tacitly acknowledged but not encouraged; and the supervisor brings the focus back to the task, namely, that of understanding and helping the client. Allowing the student to lapse into a patient role not only diverts his energies, but threatens his sense of adequacy. And in any case, the supervisor
19
would find himself frustrated in following through with any interpretation of the student's behavior because he has no contract with the student that would allow him to deal with the student's resistance.
Model Adapted to Consultation The social worker with a good command of this model can adapt his knowledge and skills readily to the requirements of consultee centered mental health consultation. Both models are learner centered and proceed on the basis of a diagnosis of psychic processes operating in the student or consultee. Both are highly structured and aim at resolving obstructions impeding learning or effective job performance. Either process aims at psychic change without the use of direct psychotherapeutic measures or the investigation of life history material. In both, corrective reality-based messages aimed at the emotional obstruction in the learner are mediated by a displacement of the discussion onto the client group.
Case Illustrations The desire here is to approach a discussion of this type of consultee-centered mental health consultation by offering an illustration from a visiting teacher group, and then to use this as the basis for developing a presentation of the theoretical and technical considerations involved. This past year two Negro men were in the visiting teacher group for the first time. During the course of the year they both presented several cases of truant children where the overt problem did not extend beyond that of truancy. That is, there was no evidence of delinquency or of other marked conflict in the home. These children simply had no motivation for attending school, and their truancy was met either with indifference or actual encouragement on the part of their parents. These children were typically from economically deprived homes where the parents were either illiterate or virtually so, and where there was no identification with middle class values regarding education. The attitude of the Negro visiting teachers toward these families was one of condemnation. They overtly spoke of the parents as "no-count," "bums," and "no good." They complained of the lack of ambition in these parents and were pessimistic regarding the child's future,
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THE COMMUNITY MENTAL HEALTH JOURNAL
feeling that, if something wasn't done, the child teacher decided he had done a good job and would turn out to be a replica of the "no good" abandoned plans to separate the children from parent. To save the child from this fate, these two the home. visiting teachers typically suggested that the child In the discussion no reference was made to the be removed from the home and put in a foster visiting teacher's emotional involvement in the home where the effects of a middle class orienta- case, and obviously no efforts were made to intion might save him. vestigate the life history sources of the interferRecently one of the teachers presented a case ing theme. The defensive projection and displaceof this nature involving two siblings, a 14-year-old ment of the countertransference anxiety onto the boy, and his 15-year-old sister. They began truant- client group was not undone, and the relaxation ing last September shortly after school began and of the interfering theme was achieved with the following the death of their mother from cancer. consultation message mediated entirely through They were out-of-wedlock children and the grand- a discussion of the client situation. The consultmother was the only remaining adult in the home. ant asks questions of the consultee about the She made idle promises to the visiting teacher to client situation only to elucidate the counterget the children off to school, but this never came transference theme in the consultee, and not to about. It became apparent that she was not only clarify the diagnosis of the client. The consultaindifferent to the truancy issue, but wanted the tion message is focused entirely on the countergirl to remain at home to help with the domestic transference problem in the eonsultee. chores. In response to my questions, the visiting teacher indicated that there were no other sig- The Consultation Model nificant problems presented by the children or the Caplan (1964) stated that the cornerhome situation. The grandmother was described as a "nice lady." In February the visiting teacher stone of this consultation method is the brought the 15-year-old girl before the juvenile maintenance of the unconscious nature of court, and that confrontation with the law was apparently sulficient to induce her to attend school, the defensive displacement in the consultee which she has done with regularity since that which allows the consultant to discuss the time. The visiting teacher expressed open hostility theme upsetting the consultee by discussing toward the girl and voiced his earlier resolve the client. This means, of course, that the that he would see to it that she stayed in school. consultant must work against the developMore recently, the teacher brought the 14-yearold brother into court with the recommendation ment of insight i n the consultee, which that he be placed in detention, and this was ac- would lead h i m to connect the client's difficomplished. The boy's detention posed, for the culties and his personal emotional probvisiting teacher, the problem of a disposition for lems. The displacement i n the consultee the child following his release. He pessimistically protects him from facing his own psychopredicted that the boy would not attend school and expressed reservations as to whether the in- logical problems, and ~if he becomes aware fluence of the court would continue to hold in of the personal link between himself and the fall when the girl would normally resume the client, the displacement is weakened or school. He was strongly thinking of recommend- undone. The consultee will then feel exing to the court that both children be placed in posed, anxiety develops, and his attention foster homes. and energies are diverted from understandNow the theme interference in this case, relating a n d helping the client to understanding ing to the visiting teacher's condemning attitude toward the parent, his pessimistic outlook for and helping himself. It then becomes imthe children's future in the present home situa- possible for the consultee to work out his tion, and his rescue fantasy that would have led own problems in terms of the client. him to separate these children from their natural This kind of development must be home, was the focal point around which I built my consultation message. I emphasized that avoided. Otherwise, the consultation sesthe girl had responded quite well to court inter- sion is likely to degenerate into a psychovention, that the boy had not yet been given therapeutic one and, as with the supervisory an opportunity to demonstrate how he would respond to the detention experience; otherwise, model, psychotherapy is not the function the consultation pointed to strengths in the family, of the mental health consultant. His funcwhich were mostly elicited from the teacher, and tion is that of enhancing the effectiveness to the fact that the absence of other significant of the consultee's work performance b y psychosocial pathology in the situation bespoke b r i n g i n g to bear his expert knowledge of the relative adequacy of the home environment. I expressed my feeling that the case was moving behavior on the consultee's u n d e r s t a n d i n g along well As the discussion closed, the visiting of i_he psychological aspects of his cases.
ROBERT A. PORTER Moreover, if it becomes known generally among the staff of the consultee institution that sessions with the consultant typically result in exposure of the personal problems of the consuhee, then there is likely to develop such fear, resistance, and hostility in the consultees toward the consultant that he is likely to find himself without a function in the institution at all. The mental health consultant is an expert with superior knowledge in his specialty and his role is best sustained by a respectful regard for the consultee as a peer with whom he is collaborating to get the job done. The interfering or countertransference theme in the consultee is typically manifested by the usual clinically significant reactions of anxiety, shame, guilt, anger, condemnation, and oversolicitude. His observations of the client are usually colored by preconceptions, oversimplifications, stereotyping, significant omissions, and other perceptual distortions. Typically, he feels helpless with regard to the client and fears a bad outcome for him. For instance, the delinquent client is seen as headed for prison, the retarded child will be exploited, or, in the case of the visiting teacher, the lower class child of illiterate parents will turn out to be an unambitious ne'er-do-well like his parents. This pessimistic preconception of the client is not challenged, for this would force the consuhee to reclassify the client and then the countertransference theme could not be dealt with. Reassurance that the client does not fit the consultee's preconceived pattern imposed on him might relieve his anxiety about the particular client and therewith free him to be
~I
more objective in helping the client, but then the consultee would have to find another displacement object on which to work out his problems. The consultant leaves the displacement intact and then organizes a message which will invalidate the expectation of a bad outcome. The message is designed to influence the consultee to realize that, in at least one case, reality does not confirm his fantasies of doom. In the visiting teacher case, for instance, the consultation message, which did not question the teacher's preconception of the client group, pointed to evidence in the case which demonstrated that his pessimistic prognosis for the children was not necessarily so. Caplan (1964) pointed out that since the disordered expectation is couched in terms of global inevitability, even one instance which refutes the expected outcome will have a significant effect in invalidating the preconception emanating from the countertransference anxiety. Crisis intervention is used extensively in social work practice, for it lends itself admirably to the social work task. Mental health consultation, both client centered and consuhee centered, is readily adaptable from social work models and provides a valuable addition to the working equipment of the mental health specialist. REFERENCES BROWN,G. W. Experiences of discharged chronic schizophrenic patients in various types of living group. Milbank Memorial Fund Quarterly, 1959, 37, 105-131. CAPLAN, G. Principles o] preventive psychiatry. New York: Basic Books, 1964.
CRISIS
INTERVENTION
AND
SOCIAL
WORK
MODELS
ROBERT A. PORTER, M.S.S.W.*
Crisis theory is discussed in relation to a mental health consultation project with visiting teachers. Case illustrations of preventive intervention are offered, and characteristics of cases which best lend themselves to this type of intervention are delineated. The adaptability of the supervisory model in social work to the consultation task is demonstrated. Caplan's theory of the theme interference type of consultee-eentered case consultation is illustrated in the visiting teacher project.
The increasing use of crisis intervention in social agency practice can be combined effectively with concepts of mental health consultation to form strategic preventive programs in community mental health. This paper will discuss crisis theory in relation to a mental health consultation project with visiting teachers and the adaptability of the supervisory model in social work to the consultation task. CONCEPT OF CRISIS The individual, in the course of his life span, experiences a number of developmental and accidental crises, which we
have come to know in clinical practice as the precipitating stresses leading to emotional disorder or mental illness. The developmental crises relate to such episodes as the child's first leaving home to attend school, biological changes at puberty, the establishment of an independent existence away from the parental home, marriage, childbearing, old age, and death. The accidental crises include such matters as separation and divorce, abandonment, pregnancy out of wedlock, unemployment, etc. --problems characteristically presented to social agencies. In these critical moments, the manner in which the individual copes with, or is helped to cope with, the stress
*Mr. Porter, a social worker, is Assistant Professor, and Director of Social Service, Department of Psychiatry, Emory University, School of Medicine, Atlanta, Georgia. 13
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may have far reaching consequences for his future mental health as well as that of other persons who may be caught in the problem network with him. At these times, when he is struggling to find some resolution and when his coping system is still open and fluid, he may achieve mastery of the problem without future restriction to his personality; he may compromise with the situation and find some sort of adjustment; or he may use regressive devices which will be detrimental to his future mental health. Under the emotional impact of the crisis the individual, still in the throes of problem solving, and not yet settled (or perhaps only tentatively settled) on a coping system, is more receptive to help and more subject to influence than he is once a coping system has evolved and become crystallized. Professional intervention at this point, by aiding the individual to adopt reality-based adjustive or adaptive devices, will usually yield maximum results for minimum efforts. If one succeeds in helping the individual to choose an effective coping system, it is fair to say that he has accomplished a bit of preventive psychiatry in that he has helped the individual to avert psychopathological sequelae which would result from maladaptive or maladjustive patterns. Now it is usually assumed in clinical practice that the defensive or coping pattern, which the individual uses when confronted with significant stress, is determined by predisposing factors in the individual personality. Epidemiological research done in recent years by community psychiatrists, however, call this assumption into question. These studies have concluded that the vulnerability of the individual to neurotic resolution in a crisis situation is more significantly related to factors in the social system in which the crisis occurs than to predisposing factors in the personality. For instance, Caplan (1964) cited a study done in the late 50's by a group of military psychiatrists, oriented in community psychiatry, which bears on this point. These psychiatrists have emphasized the significance for the onset and continuation of mental
disorder in a soldier of the emotional milieu of the military unit of which he is a member. Glass (1959) has shown that epidemiological data indicate that the incidence of "combat neurosis" is related to the circumstances of the combat situation rather than to previously existing personality factors in the individual exposed to stress. These situational circumstances relate to the intensity and duration of the battle, but more significantly to the degree of support given the individual by buddies, group cohesiveness, and leaders. Moreover, he showed that the defensive patterns adopted by individuals in the face of stress are molded by the social pressures of the group. [p. 141 A related study done in England by Brown (1959) concluded that the prognosis for the discharged psychiatric patient is more significantly related to factors in the social environment to which the patient returns than to the clinical diagnosis. Such studies as these stimulate a great deal of reflection regarding possibilities for preventive concepts in mental health in agency programming and administration, leadership roles, group process, social action, and community organization. Our society is equipped with a great many health, welfare, social, religious, legal, and other institutions which have direct and immediate contact with individuals in crisis situations. Mental health consultation with the caretakers who operate these institutional programs can be an effective means of preventive psychiatry. Case Illustrations
Two case illustrations of crisis intervention, selected from a group consultation project with visiting teachers, will be presented. These cases, along with similar ones not here discussed, will be used as the basis for inferring some generalizations about the characteristics of cases which best lend themselves to crisis intervention. .4 Case o] "School Phobia." A visiting teacher brought in a case of a ten-year-old, fourth grade girl, an only child, who had refused to attend school for two successive weeks at the point of referral. She was a somewhat retiring, timid little girl with tentative speech. She had good intelligence and had performed quite well academically. She was presenting the initial symptoms of the so-called "school phobia."
ROBERT A. PORTER
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It was significant that the father accompanied the father's resumption of his occupational role. the child to the interview. The mother worked and The visiting teacher, in view of her particular was unable to attend. An examination of the knowledge and skills, was not encouraged to delve child's relationships with the significant persons in deeper into it. her life revealed nothing to account for her sympIt is tempting to speculate what might have toms. Exploration of the father's current adjusthappened had this child been placed on a six ment, however, immediately yielded clinically sigmonths' waiting list at some child guidance clinic. nificant material. He had had a heart attack in Probably the maladjustive pattern in both father recent months, had become preoccupied with and child would have become so sufficiently set or fears of another such attack, and had developed so fixed that it would y i d d only to extensive considerable anxiety about death. He had been a psychotherapeutie intervention. Meantime, the mechanic for many years, but had given up his secondary complications of both a psychic and job in favor of doing farm work on the small social nature would have made the therapeutic acreage where he lived so that he might be close task a more complex and belabored one. The to home in the event of another heart attack. His eventual interdisciplinary diagnostic study, six wife, of course, was not at home during the day. months removed from the onset of the problem, As the father revealed his fears and anxieties would probably find the isolation and identificaabout himself, the child indicated that she was tion of the precipitating stress more difficult. Of fully aware of them. She acknowledged and could course, if the case had been admitted to outtalk about her fear that her father might die patient treatment at a later date, both father and while she was away at school. The father had child may well have had their other problems effectively communicated to the child his need for attended to. Preventive psychiatry, however, is her to remain at home as a symbol of security and aimed primarily at the prevention of mental illprotection for himself in the event of the feared ness and incapacitating emotional disorder, and catastrophe, yet he was consciously quite amazed cannot aspire, at this stage of our knowledge, if to learn of the burden which his anxiety about ever, to making maximally healthy persons out himself had imposed on the child. He was enof all human beings. couraged to seek medical assessment of his heart .4 Case o/Rebellion. The second case concerns condition so that he might gain a realistic pera 14-year-old Negro girl who was referred for speetive of the limitations it imposed. The following week the visiting teacher reported that the recent school failure, truancy, and sexually actingfather had returned to his earlier job as auto out behavior. At home the girl had become passively rebellious and difficult to deal with. The mechanic and that the ehild had returned to school became alarmed when the girl was disschool. A follow-up investigation a year later recovered nude in an apartment near the school vealed that the child had had no further recurfence of the school phobia. with a group of teen-agers. The girl was referred While one might attribute the dramatic results last November and had been presenting diffieuhy in this case to a good bit of luck, a closer analysis since the beginning of the school term. Previously her academic achievement was good and she had of the circumstances of the ease offers a more gotten along quite well at home and at school. She satisfying explanation. Most importantly, the ease was detected early and referred promptly by the appeared for the interview with her grandmother visiting teacher. One can only eonelude, judging who had raised her from infancy. The child was from the change in both father and child, that born out-of-wedlock and her natural mother had the maladjustive coping system which both had moved to the midwest soon after her birth. The been using had not yet become firmly crystallized. grandmother was a lower middle class woman with Focusing the anxiety for both father and child strong middle class moral values. She was a little and discussing, mostly by implication, the negative rigid but quite maternal, adequate, mature, and giving. No headway was made in understanding consequences for both of the maladjustive patterns they were using to cope with this anxiety the girl's behavior until she was questioned about was apparently all that was needed to motivate her natural mother. This proved to be a highly them to use a healthier pattern. No treatment sensitive area; she disselved into tears when it was used, certainly not in the usual psychothera- was suggested that she missed her mother very peutie sense, and neither father nor child was much. She then revealed that her natural mother pushed into a patient role. Neither the father's had visited her three months previously, for the depression and self-destructive impulses nor the first time in five years, and on departing had child's generally inhibited demeanor went unobpromised to send the girl bus fare so that she served clinically. However, the father did not might visit the mother in the midwest Meanwhile, present himself as a eandidate for psychotherapy, the girl's older brother, who had also been raised and one did not want to demoralize him by sugby the grandmother, did visit the natural mother gesting it, unless his subsequent behavior, as and returned to report that the mother continued observed by the visiting teacher, should indicate to be as promiscuous as the grandmother had that this step should be taken. Resolution of the difficulty was achieved at the social problem level, known her to be in earlier years. The grandmother, feeling the mother would he a bad influence, namely, by the child's return to school and by
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thereupon refused to let the girl visit her mother. It was from this point that the girl's difficult behavior began to develop. In the interview it became apparent that the girl had idealized her absent mother and refused to believe the negative reports about her. She was quite depressed in the interview, did little talking, and cried most of the time. The grandmother had made no connection between the earlier conflict situation and the girl's current behavior difficulties. She accepted the connection which was made for her, was able to identify with the girl's sense of loss and anger, and accepted the suggestion that she let the girl visit the mother. I felt safe in making this suggestion for two reasons: (a) a continuation of the girl's current behavior pattern could only lead to a worsening of the situation and to a fulfillment of the grandmother's fears; and (b), the rather adequate nurturance of this child by her grandmother throughout her earlier life made it unlikely that she would be susceptible to negative influence from the mother. The grandmother w~s given considerable support in this regard. The visiting teacher subsequently reported that the child had returned to school; and six months later, there has been no further evidence of truancy or of promiscuous behavior. She is achieving academically at her earlier level. I later had occasion to see the grandmother a second time, and learned that she had promised to let the girl visit her mother at the end of the school year and that they had talked out many of their feelings about their earlier conflict. Again, it is interesting to consider what might have happened to the girl had her problem behavior continued for another six months. If the grandmother had been more adequate to the child's needs at this strategic moment in her life, would the maladjustive behavior have developed at all? Was the girl's choice of behavioral response determined primarily by predisposing factors in her personality, or was it a socially prescribed pattern adopted from her peers who were involved in the same behavior? It should be emphasized that the intervening activities on my part were primarily directed toward the grandmother rather than the girl.
Some Generalizations A few generalizations regarding the characteristics of those cases which most readily lend themselves to this kind of preventive intervention can be made: 1. The onset of the psychosocial problem is usually clear cut, often even dramatic. 2. The level of adjustment prior to the crisis situation, although it may have been neurotic, is stable in the homeostatic sense.
3. Judging from the fact that the focal anxieties are easily elicited, and that the change in behavior subsequent to intervention m a y be as dramatic as the change in behavior following the crisis situation, one must conclude that the emergency-coping pattern used by the individual is not yet fixed. Or, put in terms of the theory of neurosis, we might say that the adjustment reaction is largely situational and has not yet been firmly internalized. This might be contrasted with the chronically neurotic or character disordered personality where the repressive forces are so strongly entrenched that anxiety ~s firmly bound by a variety of defenses, especially denial, displacement, etc. 4. The nascent state of the adjustment reaction, characterized by high anxiety levels, and the exigencies of the crisis situation, usually characterized by considerable social pressures, engenders a dependency in the client which makes him most susceptible to influence. Once the crisis has passed and the maladjustive behavior pattern is fixed, motivation for help may be proportionately reduced. 5. The crisis situation does not seem to be a one person phenomenon. The crisis is usually generated out of an intimate, interpersonal complex. In case work, of course, we look closely at the social role relationships, which are always reciprocal, and for interruptions in complementary nurturance. Breakdown in the one part always has repercussions for the reciprocal part. ner or partners. 6. The parties involved in the crisis situation obviously have a knowledge of the social problem or behavioral difficulty for which they seek help. Investigation will reveal that they also have a conscious knowledge of the precipitating conflict or stress, but that they usually do not make a connection between the two. 7. Treatment of the crisis situation typically involves the identification and focusing of the anxiety, the relating of this to the precipitating stress or conflict, the yen-
ROBERT A. PORTER tilation and communication among the parties of the dormant feelings about the conflict or stress situation, and the interjection by the therapist of his corrective reality-based observations and judgments which permit the client to find a more adaptive method of problem solution. Investigation of the crisis situation or problem behavior generally does not need to exceed the bounds of the current life situation. Examination of current social role relationships and environmental influence will usually yield the genetic data which will account for the crisis situation and the emergency behavior. Exploration of early life experiences, while perhaps enlightening, yields little or no data of relevance to the treatment task. Character structure can usually be adequately discerned in the current context. Anxiety is identified as it fulminates when sensitive areas are touched. This task is made easy by the fact that the anxiety is as yet poorly defended against. It is not usually met vigorously with denim or other defensive maneuvers. As the parties ventilate the impounded affect surrounding the conflict or stress situation, with encouragement from the therapist, anxiety levels are lowered and corrective adjustments tend to be made. The interjection by the therapist of his reality-based observations and judgments aid in this process. The impounded affect is almost entirely contained at preconscious levels. The social pressure implicit in the visiting teacher's follow-up contacts, along with the support he offers, constitutes an important contribution to the client's sustained efforts at problem solution. 8. Preventive intervention may focus more treatment actively on collaterals in the social system network of the primary client than on the client himself. This would, of course, be consistent with the research findings of the community psychiatrists, quoted above, to the effect that susceptibility of the individual to neurotic resolution or other maladaptive response to crisis appears to be more significantly related to inadequate nurturance in the social milieu than to predisposing factors in the personality. In the case of the school phobic
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girl, it would certainly appear that the father's return to work, for all the shifting in his psychic economy which that act represented, was the crucial factor which released the child from the burden of anxiety which kept her from attending school. And in the second case of the actingout teen-ager, it would seem that the relaxation of the rigidity in the grandmother was the principal factor which permitted the child to resume her earlier pattern of stable adjustment. We might look at the matter another way by asking, in reference to the first case, whether the little girl would ever have developed the school phobia had the father not become so anxious about his own health; or, in the second case, whether we would ever have come t o know the teen-age girl if her grandmother had been more understanding of the child's needs when she was confronted with the brutal facts about her natural mother. 9. Early detection and referral are crucial to the success of this type of preventive intervention. The location of the mental health consultant in an institutional program such as the public school system permits maximum exploitation of opportunities for preventive treatment. 10. This kind of preventive intervention requires a considerable amount of activity on the part of the consultant. The professional passivity of analytically-oriented psychotherapy will not work in these kinds of situations. The initial or exploratory phase of the interview, where one is attempting to identify the anxiety and establish its cause, may move more in the traditionally passive approach. However, once this information is established, effective intervention requires a fairly active playback by the consultant of his assessment in a fashion appropriate to the vernacular and level of understanding of the client. The cases on which these generalizations are based are fairly simple ones, if any behavior can be said to be simple, in the sense that the psychodynamic formulation is fairly easily established, and the client is easily susceptible to remedial or reparative influence. However, it is probable that
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more complex cases, if approached with the same spirit of preventive intervention, will yield to attempts at classification and the development of modifications of this approach appropriate to the differing levels of complexity of the cases studied. CONSULTEE-CENTERED CASE CONSULTATION So far the discussion has been directed toward client-centered case consultations in crisis intervention. The topic now will shift to a type of mental health consultation which focuses on the alleviation in the consultee of countertransference phenomena which obstruct his efficient and objective treatment of the client. This kind of consultation can be readily adapted from the supervisory model in social work. The client is not seen by the consultant, and the process focuses entirely around the case material presented by the consultee. A brief outline of the supervisory model in social work will be described as this relates to the emerging body of consultation theory in community psychiatry and will be followed by an illustration of this type of consultation in my visiting teacher group using Caplan's (1964) concept of the theme interference, reduction type of consultee-centered, case consultation.
The Supervision Model Social work supervision is somewhat different from its counterpart in psychiatry. The learner in any of the mental health disciplines will inevitably find that certain unresolved problems in his own personality will at times interfere with the efficiency of his efforts to help his client or patient. Psychiatry typically handles this problem by encouraging the resident to seek some type of psychotherapeutic experience as a part of his training program. Psychiatric supervision, therefore, remains primarily patient centered. That is, the supervisor addresses his efforts primarily to helping the resident understand the complexities of diagnosis and treatment with reference to his patient. Social work, on the other hand, cannot generally rely on a formal thera-
peutic experience as a safety valve or control over the patient needs of the social work student, and has had to build into its supervisory process a device for dealing with countertransference in the learner. Although this is not a psychotherapeutic device, psychic change in the learner is achieved. Supervision in social work is largely learner centered, rather than client centered, and we establish an educational diagnosis of each student which prescribes the nature of much of our supervisory task. The educational diagnosis is largely an assessment of the student's capacities and learning blocks. For instance, interruption of the learning process in the student may be indicated by undue resistance to the supervisor as the student struggles to shift his loyalties from past mentors with a different theoretical frame of reference to present ones, or by regressive behavior as he demonstrates that his intellectual grasp of theoretical considerations is quite in advance of his development of skills to implement his knowledge. Not infrequently, however, the learning task may be interfered with by the intrusion of a countertransference phenomenon, evoked by the life situation or problem of the client, so that the student becomes unable to perceive his client realistically or to offer him effective help. For instance, a student in a child protective agency may be assigned a case in which he must explore evidence of alleged parental neglect in a mother who apparently failed to make adequate provision for supervision of her children in her absence while working. Following his interview of the mother, the student reports to his supervisor an array of evidence to demonstrate that the mother is indeed quite neglectful and concludes that the child should be taken from her. He is somewhat emotional in his presentation, perhaps even moralistic or punitive in his attitude toward the mother. While he may report some evidence of the mother's adequacy, he assesses it lightly, and shows little understanding of the mother's anxieties and little or no disposition to help her. The clue to the student's countertransference problem lies in his overidentification
ROBERT A. PORTER with the victimized child, with his stereotyped perception of the mother, and with his distorted or skewed data collection. Or the student in a family service agency, working with the depressed wife of a man who is threatening divorce, may feel that he must save the marriage at all costs and adopts the same hostile attitudes toward the husband as his client. The wise supervisor will not direct the student's attention to unresolved problems in himself as this would not only increase his anxiety and invite resistance, but also convert the supervisory hour into a therapeutic session with the student. Instead, he will keep the discussion on the client's problem situation and emphasize evidence in the case which will serve to counteract the student's distorted or stereotyped perception of the client. In the first illustration above, he might invite a discussion of the mother's anxieties and needs, or point to evidence of the mother's adequacy. The supervisor's essential aim is to loosen the student's neurotic perception and to hold out the prospect of a reality-based resolution. In a sense, this is the essential goal of the psychotherapeutic encounter, though it is unlike it in that the therapeutic message is mediated indirectly through a discussion of the client's, rather than the student's, problem. The validity of this technique is demonstrated only as the student is freed to help his client, or by his demonstration in subsequent but similar cases that he is able to perceive his client more objectively. Note particularly, in this supervisory model, that it is not necessary for the supervisor to explore the life history material in the student that would explain or account for the countertransference phenomenon; in fact, such a procedure is definitely contra-indicated. Even if the student voluntarily injects anamnestic material into the discussion, it is tacitly acknowledged but not encouraged; and the supervisor brings the focus back to the task, namely, that of understanding and helping the client. Allowing the student to lapse into a patient role not only diverts his energies, but threatens his sense of adequacy. And in any case, the supervisor
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would find himself frustrated in following through with any interpretation of the student's behavior because he has no contract with the student that would allow him to deal with the student's resistance.
Model Adapted to Consultation The social worker with a good command of this model can adapt his knowledge and skills readily to the requirements of consultee centered mental health consultation. Both models are learner centered and proceed on the basis of a diagnosis of psychic processes operating in the student or consultee. Both are highly structured and aim at resolving obstructions impeding learning or effective job performance. Either process aims at psychic change without the use of direct psychotherapeutic measures or the investigation of life history material. In both, corrective reality-based messages aimed at the emotional obstruction in the learner are mediated by a displacement of the discussion onto the client group.
Case Illustrations The desire here is to approach a discussion of this type of consultee-centered mental health consultation by offering an illustration from a visiting teacher group, and then to use this as the basis for developing a presentation of the theoretical and technical considerations involved. This past year two Negro men were in the visiting teacher group for the first time. During the course of the year they both presented several cases of truant children where the overt problem did not extend beyond that of truancy. That is, there was no evidence of delinquency or of other marked conflict in the home. These children simply had no motivation for attending school, and their truancy was met either with indifference or actual encouragement on the part of their parents. These children were typically from economically deprived homes where the parents were either illiterate or virtually so, and where there was no identification with middle class values regarding education. The attitude of the Negro visiting teachers toward these families was one of condemnation. They overtly spoke of the parents as "no-count," "bums," and "no good." They complained of the lack of ambition in these parents and were pessimistic regarding the child's future,
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feeling that, if something wasn't done, the child teacher decided he had done a good job and would turn out to be a replica of the "no good" abandoned plans to separate the children from parent. To save the child from this fate, these two the home. visiting teachers typically suggested that the child In the discussion no reference was made to the be removed from the home and put in a foster visiting teacher's emotional involvement in the home where the effects of a middle class orienta- case, and obviously no efforts were made to intion might save him. vestigate the life history sources of the interferRecently one of the teachers presented a case ing theme. The defensive projection and displaceof this nature involving two siblings, a 14-year-old ment of the countertransference anxiety onto the boy, and his 15-year-old sister. They began truant- client group was not undone, and the relaxation ing last September shortly after school began and of the interfering theme was achieved with the following the death of their mother from cancer. consultation message mediated entirely through They were out-of-wedlock children and the grand- a discussion of the client situation. The consultmother was the only remaining adult in the home. ant asks questions of the consultee about the She made idle promises to the visiting teacher to client situation only to elucidate the counterget the children off to school, but this never came transference theme in the consultee, and not to about. It became apparent that she was not only clarify the diagnosis of the client. The consultaindifferent to the truancy issue, but wanted the tion message is focused entirely on the countergirl to remain at home to help with the domestic transference problem in the eonsultee. chores. In response to my questions, the visiting teacher indicated that there were no other sig- The Consultation Model nificant problems presented by the children or the Caplan (1964) stated that the cornerhome situation. The grandmother was described as a "nice lady." In February the visiting teacher stone of this consultation method is the brought the 15-year-old girl before the juvenile maintenance of the unconscious nature of court, and that confrontation with the law was apparently sulficient to induce her to attend school, the defensive displacement in the consultee which she has done with regularity since that which allows the consultant to discuss the time. The visiting teacher expressed open hostility theme upsetting the consultee by discussing toward the girl and voiced his earlier resolve the client. This means, of course, that the that he would see to it that she stayed in school. consultant must work against the developMore recently, the teacher brought the 14-yearold brother into court with the recommendation ment of insight i n the consultee, which that he be placed in detention, and this was ac- would lead h i m to connect the client's difficomplished. The boy's detention posed, for the culties and his personal emotional probvisiting teacher, the problem of a disposition for lems. The displacement i n the consultee the child following his release. He pessimistically protects him from facing his own psychopredicted that the boy would not attend school and expressed reservations as to whether the in- logical problems, and ~if he becomes aware fluence of the court would continue to hold in of the personal link between himself and the fall when the girl would normally resume the client, the displacement is weakened or school. He was strongly thinking of recommend- undone. The consultee will then feel exing to the court that both children be placed in posed, anxiety develops, and his attention foster homes. and energies are diverted from understandNow the theme interference in this case, relating a n d helping the client to understanding ing to the visiting teacher's condemning attitude toward the parent, his pessimistic outlook for and helping himself. It then becomes imthe children's future in the present home situa- possible for the consultee to work out his tion, and his rescue fantasy that would have led own problems in terms of the client. him to separate these children from their natural This kind of development must be home, was the focal point around which I built my consultation message. I emphasized that avoided. Otherwise, the consultation sesthe girl had responded quite well to court inter- sion is likely to degenerate into a psychovention, that the boy had not yet been given therapeutic one and, as with the supervisory an opportunity to demonstrate how he would respond to the detention experience; otherwise, model, psychotherapy is not the function the consultation pointed to strengths in the family, of the mental health consultant. His funcwhich were mostly elicited from the teacher, and tion is that of enhancing the effectiveness to the fact that the absence of other significant of the consultee's work performance b y psychosocial pathology in the situation bespoke b r i n g i n g to bear his expert knowledge of the relative adequacy of the home environment. I expressed my feeling that the case was moving behavior on the consultee's u n d e r s t a n d i n g along well As the discussion closed, the visiting of i_he psychological aspects of his cases.
ROBERT A. PORTER Moreover, if it becomes known generally among the staff of the consultee institution that sessions with the consultant typically result in exposure of the personal problems of the consuhee, then there is likely to develop such fear, resistance, and hostility in the consultees toward the consultant that he is likely to find himself without a function in the institution at all. The mental health consultant is an expert with superior knowledge in his specialty and his role is best sustained by a respectful regard for the consultee as a peer with whom he is collaborating to get the job done. The interfering or countertransference theme in the consultee is typically manifested by the usual clinically significant reactions of anxiety, shame, guilt, anger, condemnation, and oversolicitude. His observations of the client are usually colored by preconceptions, oversimplifications, stereotyping, significant omissions, and other perceptual distortions. Typically, he feels helpless with regard to the client and fears a bad outcome for him. For instance, the delinquent client is seen as headed for prison, the retarded child will be exploited, or, in the case of the visiting teacher, the lower class child of illiterate parents will turn out to be an unambitious ne'er-do-well like his parents. This pessimistic preconception of the client is not challenged, for this would force the consuhee to reclassify the client and then the countertransference theme could not be dealt with. Reassurance that the client does not fit the consultee's preconceived pattern imposed on him might relieve his anxiety about the particular client and therewith free him to be
~I
more objective in helping the client, but then the consultee would have to find another displacement object on which to work out his problems. The consultant leaves the displacement intact and then organizes a message which will invalidate the expectation of a bad outcome. The message is designed to influence the consultee to realize that, in at least one case, reality does not confirm his fantasies of doom. In the visiting teacher case, for instance, the consultation message, which did not question the teacher's preconception of the client group, pointed to evidence in the case which demonstrated that his pessimistic prognosis for the children was not necessarily so. Caplan (1964) pointed out that since the disordered expectation is couched in terms of global inevitability, even one instance which refutes the expected outcome will have a significant effect in invalidating the preconception emanating from the countertransference anxiety. Crisis intervention is used extensively in social work practice, for it lends itself admirably to the social work task. Mental health consultation, both client centered and consuhee centered, is readily adaptable from social work models and provides a valuable addition to the working equipment of the mental health specialist. REFERENCES BROWN,G. W. Experiences of discharged chronic schizophrenic patients in various types of living group. Milbank Memorial Fund Quarterly, 1959, 37, 105-131. CAPLAN, G. Principles o] preventive psychiatry. New York: Basic Books, 1964.
