The Child's Participation in Conjoint Family Therapy
Herta A. Guttman, M.D.
Conjoint family therapy developed out of the realization that individual treatment of the preadolescent child can founder when the child is really a presenting symptom, either of a particular parent's malaise or of a family problem. Ultimately, this insight led to focusing on the entire family as a unit, the disturbed child being considered simply as one part of a system in which people reciprocally affect and are affected by one another (Stachowiak, 19fiH). Within such a conceptual framework, the child should be considered a significant and integral member of the family, whether or not he is the presenting problem (Augenbraun and Tasem, 19fifi; Tasem et al., 1965). However, it has been my own and others' experience that family therapists-particularly those who have little or no training in child therapy-do not pay as much attention to the child in actual practice as they do in theory, especially when the child is not the identified patient (Zilbach et al., 1972). His participation is often on a nonverbal level, and he does not usually respond to direct questions which f(lCUS on the "family problem." He seems to sit quietly aloof, or alternatively to squirm, wriggle. ask for drinks of water, or ask irrelevant questions. Sometimes such children become wildly uncontrollable. thereby increasing the parents' and the therapist's anxiety and frustration. In such cases, the therapist may muster enough interest to exhort the parents to Dr. Gultm(l/I is the Director oj Famil» Theratr; Training at till' [euish General Hospital, Montreal, QlUhec. The examples cited ill this paper comefromfamilies prHmwl(v mteroieioed hy the author, (L' uiel! as cases intervieuied by the [ollounng therapists: Dr. P. Beck, Dr. R. Feldman awl MH. C. Sherrard, Dr. K. Geagea, MH. S. Macko», Dr. j. Pari" DH. 1. Hebner and D. Frank, DH. G. Schneiderman and R. Lajoie, and Dr. M. Stein. Reprint' may he requested/rom the author, Institute oj Community and Family Psychiatry, 433J Cote Ste. Catherine Road, Montreal, Qurhec.
490
The Child in Conjoint Family Thrrapy
491
control the child. As often as not, he concludes that this child's presence is not really serving a useful purpose and asks that he be left at home next time. From then on, the therapist concentrates on the older family members. The technique of involving the younger child in conjoint family situations is an important but neglected aspect of the teaching of family therapy. It is generally agreed that the ideal way of including him or her would involve having play materials at hand, since drawing and other forms of play-as well as movement and vocalization-are his favored mode of communication. However, children's play within the usual office setting is often considered to be disruptive, distracting, and messy. Supervisors of family therapy often communicate to their students that it is best to ignore or eliminate younger children from the therapy situation because it requires inordinate insight, an ultra-large playroom, and lots of equipment to do justice to the child's potential activities. Even those authors who have used art therapy to facilitate and clarify family interaction seem to view this as a group project, rather than as a means of integrating the child's experiences and feelings into the treatment of the familv (Kwiatkowska, 19(7). I would like to exa'~line the possibility that a child can help the therapist understand the whole family system as much as, and sometimes more than, other familv members. Moreover, the therapist can play an educative role 1'01', adult family members by showing them how one may understand and respond to the child's communications as legitimate comments on his satisfactions or dissatisfactions with family functioning. In my opinion, this can be done by any therapist who has a conventional understanding of the possible symbolic significance of children's verbal and nonverbal activity. It does not require a great deal of equipment, and honors in the observance rather than in the breach a commitment to treating the family as a whole. The following examples illustrate some ways in which the child, in his behavior and plav, "acts o ut " certain family feelings and problems, and some ways in which these communications can be fully integrated into the therapeutic process. (:ASE EXAMPl.ES
Communicating a Family Problem by Chanl.,rinK or Preseroing the Seating Arrangement
I. A middle-class family consisting of the parents, the identified patient-a bov of I:-l-and an I l-vcar-old daughter, had been in
492
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treatment for four months. They had been referred for therapy by the juvenile court because the son had systematically stolen electronic equipment from various houses in his neighborhood over a period of a year. During the first months, the seating arrangement was such that the parents sat on either side of the therapist, with the children between them, the girl nearer the mother and the boy nearer the father. The boy was consistently attacked by the mother, and alternately attacked and protected by his rather pompous father. The parents did not ar~ue directly. The II-year-old girl was usually silent, but she would become sad and protective toward her mother whenever the latter cried. As therapy progressed, it became clear that the father would have to confront his wife in order to stop her persistent attacks on the SOIL This became dramatically obvious on the day that the daughter marched into the office and took her father's chair, thereby forcing him to sit between her brother and mother and really make a choice. The therapist interpreted her behavior accordingly. This enabled the mother to realize that she had an unrealistic fear of losing' her husband's affection if he loved his son as well as her. This was probably derived from her early experience with her parents, who doted on her younger brother and excluded her. The father had been afraid of hurting his wife's feelings by coming to the son's rescue. As he better understood the basis of her reaction, he became more courageous about intervening in the mother-son deadlock. 2. In a family consisting of the parents and four children, a dominant theme concerned the mother's closeness to and control over the children, whereas the father was relatively distant and isolated. Usually, the parents sat at either end of a row, with the children between them. It soon became apparent that the state of family affairs could be most accurately ~auged by changes in the members' positions. When the father became less isolated in the family, the youngest child, a 4-year-old who always sat next to his mother, be~an sitting next to him. 3. A l-l-year-old boy, who had always been the parents' scape~oat, was sitting between them, while his 5-year-old brother played with blocks on the floor. With the therapist's help, the parents began confronting one another about their mutual disappointment. The older boy became restless and anxious, and finally moved to a more peripheral chair, again with the therapist's encouragement. A few minutes later, the younger child left his toys and came to sit in the empty chair, as if he wished to take his brother's vacated position, thereby restoring a safe distance between their warrin~ parents.
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Communicating a Family Problem Through Aggressive Play
I. In a family in which a stepfather had recently died, the 10year-old son was reported to be very aggressive toward other children at school. Mother, son, and (i-year-old daughter came for therapy. During several sessions, the boy repeatedly punched a toy elephant while the therapist and the mother were discussing the family's reaction to their recent bereavement. His behavior became even more aggressive when they discussed the mother's apathy and indifference toward the children since her husband's death. When it was pointed out that the son was punching his elephant as if he was angry with his stepfather for dying, and with his mother for her indifference, his aggressive behavior within and outside therapy sessions decreased markedly. 2. A woman who suffered from a peptic ulcer was referred by a gastroenterologist for a psychiatric opinion on the advisability of performing a gastrectomy. She said that she considered her main problem to be her 5-year-old son, whom she described as being "uncontrollable." She had no difficulties with her two older daughters. It was suggested that she and her husband come with the son for a conjoint interview. The boy was mischievous, disobedient, and restless. He so singlemindedly wished to leave the room that his mother finally had to sit in front of the office door to prevent him from leaving. Meanwhile, the father sat rigidly in his chair, physically rejected all the boy's attempts to play with him, and did nothing to assist the mother in controlling the child as he became more and more destructive with the office furniture and furnishings. The therapist interpreted the child's behavior and the wife's ulcer as being responses to the father's withdrawal and lack of support, empathy, or playful involvement with his son or with his wife. At this interpretation, the wife began to cry and the child quietened. The husband first denied that his wife was crying at all, then became increasingly defensive as his behavior was connected with his own experiences with his distant father. This family subsequently refused further treatment, and the mother had a gastrectomy. Clearly, this family's relationships were so maladaptive that it was difficult to select an intervention which might alter their rigid defenses. In retrospect, the therapist might have been more effective had she limited her interpretation to each parent's interaction with the child, and ignored the parental relationship for the moment. This might have permitted the mother greater freedom to express her anger and frustration and to move out of her sacrificial role.
494
Herta A. Guttman
Deflecting Attention Through Provocative Behavior
I. During individual therapy, a young woman constantly complained that her husband would passively withdraw into silence whenever she became annoyed with him. The therapist asked to see her together with her husband and 4-year-old daughter. As the therapist tried to get the parents to discuss their problem, the little girl became increasingly provocative. She insisted on sitting between her parents, on her father's chair, and kept pushing her father off his chair so that interaction between the parents became impossible. The therapist intervened and pointed out that the child was behaving toward her father much as her mother did, and that he responded to them both by withdrawing and thereby increasing their anger and anxiety, rather than reassuring them by taking a firm stand. When the father became more forceful and made the child go back to her own chair, she sat quietly while the parents proceeded to speak to each other. 2. A family with three children was so seated that the 6-year-old daughter was sitting between her parents. As the mother began to complain of her husband's dependency, the child repeatedly interposed herself physically so that the mother's attention was defleeted to her and she began scolding her instead of the father. It emerged that this behavior reflected the little girl's fear that she would lose a second father, since her mother and natural father had been divorced a number of years previously. 3. An 8-year-old boy who had made several suicidal gestures by taking aspirin had been treated individually while his parents were concurrently receiving conjoint marital therapy. When the whole family was seen together, the parents began discussing their mutual sadness and disappointment. The identified patient began distracting their and the therapist's attention by grimacing and laughing with his younger sister, much as he had distracted them at home by his suicidal gestures. When this was pointed out, the son was able to tell them how angry and frightened he became when they quarreled, and how he wished to "get away" from having to act as a judge between them. 4. In a family which asked for consultation because of the delinquent behavior of a 15-year-old daughter, her II-year-old brother kept whispering and diverting his sister's attention by making her laugh. This happened whenever the therapist touched on her wish to be valued by her demanding and perfectionist father, her sadness at being left to fend for herself, and her defense of being "tough." The boy's joking seemed to help his sister sustain this
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defensiveness, and probably helped him keep his favored position in the family as well. Communicating Empath» with and Fl'l'lings about a Depressed, Preoccupied Parent
I. A family consisting of two parents and three young children had undergone a series of major life crises: the father's father and the mother's two parents had been seriously ill within the last year; the father's brother had died of severe asthma, and the mother's brother had died by apparently accidental drowning; the youngest child, a boy of 8 months, was presently in the hospital with severe asthma. The mother, a constricted, dutiful person, denied that she was still preoccupied with her younger brother's death; yet, as the session progressed and she became more comfortable about talking about her feelings, she became obviously depressed and began to weep. At that point, the small 3-year-old boy began to call attention to his shoelaces with a piercing cry ("Mummy, Mummy"), as if to save his mother from her feelings by diverting her attention to himself. 2. An immigrant mother, whose 7-year-old son had a learning problem, blamed herself for not paying sufficient attention to him at the time of immigration when she was very homesick and when there was also a new baby to care for. As she described this, the boy began sucking his thumb while his smaller sister rummaged in the mother's handbag for cookies. Both children seemed to be expressing empathy for the mother and anxiety aboutlosing her attention (cookies). Communicating Feelings ofHelptessness and Compensatory Protectiveness
I. A couple, in marital therapy for six months, were both rather immature people, and so egocentrically preoccupied that they had enormous difficulty in developing any mutuality in their relationship, even in helping each other with the practiced tasks of everyday life. These problems had become vividly apparent during marital therapy, and the therapist had repeatedly pointed out that they were content with each other only when playing together as children, and never when having to behave as responsible adults. During the seventh month of therapy, they reported that their 7-year-old daughter had suddenly become afraid to leave the house to go out to play with her friends. A family session was held, during which time the child drew a picture of a royal family. A leu"ge princess was sweeping the floor with a broom in the fore-
496
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~round, while her parents, the kin~ and queen, who were much smaller people in the background, were not doing anything. She then added a fourth figure-intermediate in size-whom she identified as a prince, the princess's little brother. The little girl agreed with the interpretation that she was afraid to leave the house to play because she felt she had to help her parents, and that she wished for a baby brother who could be her companion. The parents subsequently reported that their daughter had become more out~oin~ since the interview. 2. A (i-year-okl girl repeatedly denied that her mother was sad, although the mother was cryin~ about her frustration, sadness, and helplessness at having to manage everything alone, without her husband's help. The child finally said, "I don't want Mommy to be sad, and she isn't!"
Communicating Fnlings of Guilt
A 7-year-old boy began worrying about the videotape cameras and wondering whether people who knew the family were watchin~ them on TV, when his mother started talking about feeling ~uilty that she had blamed him for being "bad " rather than sick. before she had realized that he was a hyperactive child and required medication. Communicating till' Identified Patient's Problem of Passive Dependence
I. A (i-year-olcl girl drew a picture of her 8-year-old brother as a female ballet dancer, dressed in pink, while her parents and the therapist were discussing her brother's babyish behavior and the ways in which the mother fostered it. Although the mother energetically denied it, the drawing confirmed this more effectively than did anything said by her husband or by the therapist. The son, who had hitherto been plaintive and infantile during the therapy session. became quieter and behaved more appropriately for his age. Although the family refused conjoint therapy, the mother continued in individual treatment, and later reported that this observation had motivated her and her husband to make some changes in their handling of the child. 2. A 6-year-old girl drew a picture in which there was a tiny girl in the distance, whom she identified as her 12-vear-old brother, and a larger person in the foreground, whom she 'id e n tified as herself. This drawing reflected the parents' perception of her being much more independent and mature than her overprotected, whiny, diabetic brother. Later in treatment , this girl drew another
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pict u rc of her brot her as a large bo y in the foreground. This reflected a substantial improvement in his independent and autonomous behavior. Communicating Feelings about Successful Family Therapy I. The 12-year-old di abetic boy mentioned a bo ve drew pictures of various objects in the office, as well as composite portraits of his parents and the therapist during the last famil y session. The famil y agreed that the drawing reflected the famil y's feeling of being in greater harmon y, as well as their difficult y in leaving the therapist, whom they wished to incorporate into their family. 2. In the mourning family previously mentioned, both children painted many pictures in black. The boy painted warlike scenes of jet fighters or destroyers, fighting battles and going down in Hames. These pictures communicated feelings of sadness mingled with anger at the d eparted stepfather, who, as it happened, was a black man. As treatment progressed, and the family dealt with their mourning, the paintings graduall y became more colorful, and the planes and boats were se n t on more peaceful missions. DISC USSION
These descriptions demonstrate somc of the many wa ys in whi ch children communicate their own feelings, and participate in defining their famil y's problems. In man y in stances, the child tries to preserve famil y homeostasis by the various behaviors which have been described. It is he who cxpresses the family's resistance to the therapist's attempts to stimulate confrontation and change. In other instances, the child acts as the primary agent of change within the famil y because his activit y disrupts the famil y's previous equilibrium. By being constantly aware that th e children, as well as adults, preserve or disrupt family homeosta sis, the therapist can integrate the child into the treatment situation in a more meaningful way. and can begin exp lo r ing the family problem to which the child is drawing attention. This is a far more empathic and effective method than to direct "Why?" and "How?" questions at a young child (e.g., "Why are you wriggling? How do you feel when momm y and daddy fight?") . Such questions usuall y increase the child's reluctance to communicate, because he himself oftcn cannot readil y use words to describe the "why" and "how" of his perceptions. His behavior, his play, and his art co nstitu te the language through which he must and can be understood, both by the therapist and by the more
498
Herta A. Guttman
adult members of the family. Moreover, the therapist can more tactfully convey many potentially painful observations to the parents in his seemingly innocuous and aimless verbal interaction with their children (Whitaker, 19(7). To do this effectively, the therapist must constantly monitor the children's reactions, even while listening to or talking with other family members. He may not immediately draw attention to this information, but he stores it for use at some appropriate moment. Sometimes the therapist's interventions merely integrate the child into the group as a perceptive, contributing family member. Sometimes, he may wish actually to interrupt whatever else is going on, to draw attention to something the child has said or done, and to connect it with the current theme within the interview situation. Often, the child's behavior fnTIS the basis of an interpretation which draws attention to an interpersonal problem within the family. Although the use of simple toys may facilitate a child's communication, an elaborate playroom setting is certainly not a prerequisite for the emergence of behavioral clues of the kind I have described. Many of the examples which have been cited in this paper were, ill fact, observed ill a highly unlikely environment: an amphitheater in which family interviews are conducted and videotaped in front of an audience of 80 to 100 people, without any play materials at hand whatever. Nevertheless, it is more desirable and relatively easy to provide paper, crayons, building blocks, and a few simple toys, even in the setting of a private office. Aside from the more passive therapeutic stance of observing, drawing attention to, or interpreting the young child's behavior, the therapist can playa more active role. He can ask the child to draw a picture of the family, at work or at play. He can have the child take a turn in "sculpting" the family or at participating in a family game (Simon, 1972). Even then, as Ackerman (1970) has cautioned, one does well to keep one's distance at first: the child does not know the therapist and does not immediately accept a strange adult. Moreover, although active and directive methods have their place, the child's spontaneous activity is even more informative, especially at later stages in therapy when the family's relationship with the therapist is well established. It is my experience that children will rapidly become aware that their type of participation is valuable and valued by the therapist, and will quite naturally interject their comments, or will ask for appropriate play materials if they are missing at a particular session because they
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have learned to define themselves as very important members in the family. The understanding garnered from the insights of play therapy can thus be profitably combined with family therapy which is more verbally or insight-oriented. Through this technique, the young child becomes an integral part of the situation and makes his own unique, important contribution. The family therapist becomes more meaningfully committed to conjoint family therapy as the treatment of a whole system, and is more helpful to all family members in developing ways of understanding and solving their problems. SVMMARY
Family therapy, to be true to its commitment to systems theory, should be as concerned with the younger child as with all other family members, whether he is the presenting problem or not. As a rule, family therapists do not pay enough attention to the child, because to involve him requires meaningfully integrating his communications into the family svstem. Since children communicate through play, movement, ell'ld seemingly irrelevant remarks, therapists must be taught to understand and use their contributions. This paper illustrates some ways in which children's communications may be understood within a family context. Such understanding can help educate older family members regarding the children's needs and can be an important tool for meaningful therapeutic intervention in the family system.
REFERENCES ACKERMA~.:'\. W. (1~170).
Child participation in famih rlu-rupv, Fam, Proc., ~':40:{--410. B. & TAsDI. 1\1. (I~llili), Differential nxhniqucs in f.unilv interviewing' with hoth parents and preschool child. This [oumal, :):7~ 1-7:\(). KWIATKOWSKA. II. Y. (1~1l;7). Faruilv art rlu-rupv. Fam, Prot .. tl::17-",:,. StMON, R. M. (197~). Sculptin~ the familv. Fum, Pror., 11:49-57. STACIHJWtAK,.J. (;. (I ~lliH). Ps\'dlOlo~ical disturhances in children as related to disturbances in familv inll't'acrion.j. Marr. Fam .. :W: I ~:{-I ~7. TAsEM. :\1.. Al'(a:~BRAl'~. B.. & BROWN, S. L (I ~lli5). Familv ~I'OUp interviewing with the preschool child and both parents. Thisjournal, 4::nO-:HO. WHITAKER. C. A. (l~lli7). The ~rowin~ ed~e (interview). In: Trchniqurs ojFamil» Therap», ed . .J. Hale\' & L. Hoffman. :'\ew York: Basic Books. pp. ~li:)-:lfiO. Zn.BAUI,.J..I .. BER(;u .. E.. & (;ASS, C. (197~). Roll' of the youn~ child in familv therapv. In: Progress ill (;roll!J and Famil» Therap», ed. c. .J. Sa~l't' & H. S. Kaplan. :'\ew York: Brunncr/Mazcl. pp. :1H:)-:{!l~I. Al'l;ENBRAl'~.
Herta A. Guttman, M.D.
Conjoint family therapy developed out of the realization that individual treatment of the preadolescent child can founder when the child is really a presenting symptom, either of a particular parent's malaise or of a family problem. Ultimately, this insight led to focusing on the entire family as a unit, the disturbed child being considered simply as one part of a system in which people reciprocally affect and are affected by one another (Stachowiak, 19fiH). Within such a conceptual framework, the child should be considered a significant and integral member of the family, whether or not he is the presenting problem (Augenbraun and Tasem, 19fifi; Tasem et al., 1965). However, it has been my own and others' experience that family therapists-particularly those who have little or no training in child therapy-do not pay as much attention to the child in actual practice as they do in theory, especially when the child is not the identified patient (Zilbach et al., 1972). His participation is often on a nonverbal level, and he does not usually respond to direct questions which f(lCUS on the "family problem." He seems to sit quietly aloof, or alternatively to squirm, wriggle. ask for drinks of water, or ask irrelevant questions. Sometimes such children become wildly uncontrollable. thereby increasing the parents' and the therapist's anxiety and frustration. In such cases, the therapist may muster enough interest to exhort the parents to Dr. Gultm(l/I is the Director oj Famil» Theratr; Training at till' [euish General Hospital, Montreal, QlUhec. The examples cited ill this paper comefromfamilies prHmwl(v mteroieioed hy the author, (L' uiel! as cases intervieuied by the [ollounng therapists: Dr. P. Beck, Dr. R. Feldman awl MH. C. Sherrard, Dr. K. Geagea, MH. S. Macko», Dr. j. Pari" DH. 1. Hebner and D. Frank, DH. G. Schneiderman and R. Lajoie, and Dr. M. Stein. Reprint' may he requested/rom the author, Institute oj Community and Family Psychiatry, 433J Cote Ste. Catherine Road, Montreal, Qurhec.
490
The Child in Conjoint Family Thrrapy
491
control the child. As often as not, he concludes that this child's presence is not really serving a useful purpose and asks that he be left at home next time. From then on, the therapist concentrates on the older family members. The technique of involving the younger child in conjoint family situations is an important but neglected aspect of the teaching of family therapy. It is generally agreed that the ideal way of including him or her would involve having play materials at hand, since drawing and other forms of play-as well as movement and vocalization-are his favored mode of communication. However, children's play within the usual office setting is often considered to be disruptive, distracting, and messy. Supervisors of family therapy often communicate to their students that it is best to ignore or eliminate younger children from the therapy situation because it requires inordinate insight, an ultra-large playroom, and lots of equipment to do justice to the child's potential activities. Even those authors who have used art therapy to facilitate and clarify family interaction seem to view this as a group project, rather than as a means of integrating the child's experiences and feelings into the treatment of the familv (Kwiatkowska, 19(7). I would like to exa'~line the possibility that a child can help the therapist understand the whole family system as much as, and sometimes more than, other familv members. Moreover, the therapist can play an educative role 1'01', adult family members by showing them how one may understand and respond to the child's communications as legitimate comments on his satisfactions or dissatisfactions with family functioning. In my opinion, this can be done by any therapist who has a conventional understanding of the possible symbolic significance of children's verbal and nonverbal activity. It does not require a great deal of equipment, and honors in the observance rather than in the breach a commitment to treating the family as a whole. The following examples illustrate some ways in which the child, in his behavior and plav, "acts o ut " certain family feelings and problems, and some ways in which these communications can be fully integrated into the therapeutic process. (:ASE EXAMPl.ES
Communicating a Family Problem by Chanl.,rinK or Preseroing the Seating Arrangement
I. A middle-class family consisting of the parents, the identified patient-a bov of I:-l-and an I l-vcar-old daughter, had been in
492
Herta A. Guttman
treatment for four months. They had been referred for therapy by the juvenile court because the son had systematically stolen electronic equipment from various houses in his neighborhood over a period of a year. During the first months, the seating arrangement was such that the parents sat on either side of the therapist, with the children between them, the girl nearer the mother and the boy nearer the father. The boy was consistently attacked by the mother, and alternately attacked and protected by his rather pompous father. The parents did not ar~ue directly. The II-year-old girl was usually silent, but she would become sad and protective toward her mother whenever the latter cried. As therapy progressed, it became clear that the father would have to confront his wife in order to stop her persistent attacks on the SOIL This became dramatically obvious on the day that the daughter marched into the office and took her father's chair, thereby forcing him to sit between her brother and mother and really make a choice. The therapist interpreted her behavior accordingly. This enabled the mother to realize that she had an unrealistic fear of losing' her husband's affection if he loved his son as well as her. This was probably derived from her early experience with her parents, who doted on her younger brother and excluded her. The father had been afraid of hurting his wife's feelings by coming to the son's rescue. As he better understood the basis of her reaction, he became more courageous about intervening in the mother-son deadlock. 2. In a family consisting of the parents and four children, a dominant theme concerned the mother's closeness to and control over the children, whereas the father was relatively distant and isolated. Usually, the parents sat at either end of a row, with the children between them. It soon became apparent that the state of family affairs could be most accurately ~auged by changes in the members' positions. When the father became less isolated in the family, the youngest child, a 4-year-old who always sat next to his mother, be~an sitting next to him. 3. A l-l-year-old boy, who had always been the parents' scape~oat, was sitting between them, while his 5-year-old brother played with blocks on the floor. With the therapist's help, the parents began confronting one another about their mutual disappointment. The older boy became restless and anxious, and finally moved to a more peripheral chair, again with the therapist's encouragement. A few minutes later, the younger child left his toys and came to sit in the empty chair, as if he wished to take his brother's vacated position, thereby restoring a safe distance between their warrin~ parents.
The Child in Conjoint Family Therapy
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Communicating a Family Problem Through Aggressive Play
I. In a family in which a stepfather had recently died, the 10year-old son was reported to be very aggressive toward other children at school. Mother, son, and (i-year-old daughter came for therapy. During several sessions, the boy repeatedly punched a toy elephant while the therapist and the mother were discussing the family's reaction to their recent bereavement. His behavior became even more aggressive when they discussed the mother's apathy and indifference toward the children since her husband's death. When it was pointed out that the son was punching his elephant as if he was angry with his stepfather for dying, and with his mother for her indifference, his aggressive behavior within and outside therapy sessions decreased markedly. 2. A woman who suffered from a peptic ulcer was referred by a gastroenterologist for a psychiatric opinion on the advisability of performing a gastrectomy. She said that she considered her main problem to be her 5-year-old son, whom she described as being "uncontrollable." She had no difficulties with her two older daughters. It was suggested that she and her husband come with the son for a conjoint interview. The boy was mischievous, disobedient, and restless. He so singlemindedly wished to leave the room that his mother finally had to sit in front of the office door to prevent him from leaving. Meanwhile, the father sat rigidly in his chair, physically rejected all the boy's attempts to play with him, and did nothing to assist the mother in controlling the child as he became more and more destructive with the office furniture and furnishings. The therapist interpreted the child's behavior and the wife's ulcer as being responses to the father's withdrawal and lack of support, empathy, or playful involvement with his son or with his wife. At this interpretation, the wife began to cry and the child quietened. The husband first denied that his wife was crying at all, then became increasingly defensive as his behavior was connected with his own experiences with his distant father. This family subsequently refused further treatment, and the mother had a gastrectomy. Clearly, this family's relationships were so maladaptive that it was difficult to select an intervention which might alter their rigid defenses. In retrospect, the therapist might have been more effective had she limited her interpretation to each parent's interaction with the child, and ignored the parental relationship for the moment. This might have permitted the mother greater freedom to express her anger and frustration and to move out of her sacrificial role.
494
Herta A. Guttman
Deflecting Attention Through Provocative Behavior
I. During individual therapy, a young woman constantly complained that her husband would passively withdraw into silence whenever she became annoyed with him. The therapist asked to see her together with her husband and 4-year-old daughter. As the therapist tried to get the parents to discuss their problem, the little girl became increasingly provocative. She insisted on sitting between her parents, on her father's chair, and kept pushing her father off his chair so that interaction between the parents became impossible. The therapist intervened and pointed out that the child was behaving toward her father much as her mother did, and that he responded to them both by withdrawing and thereby increasing their anger and anxiety, rather than reassuring them by taking a firm stand. When the father became more forceful and made the child go back to her own chair, she sat quietly while the parents proceeded to speak to each other. 2. A family with three children was so seated that the 6-year-old daughter was sitting between her parents. As the mother began to complain of her husband's dependency, the child repeatedly interposed herself physically so that the mother's attention was defleeted to her and she began scolding her instead of the father. It emerged that this behavior reflected the little girl's fear that she would lose a second father, since her mother and natural father had been divorced a number of years previously. 3. An 8-year-old boy who had made several suicidal gestures by taking aspirin had been treated individually while his parents were concurrently receiving conjoint marital therapy. When the whole family was seen together, the parents began discussing their mutual sadness and disappointment. The identified patient began distracting their and the therapist's attention by grimacing and laughing with his younger sister, much as he had distracted them at home by his suicidal gestures. When this was pointed out, the son was able to tell them how angry and frightened he became when they quarreled, and how he wished to "get away" from having to act as a judge between them. 4. In a family which asked for consultation because of the delinquent behavior of a 15-year-old daughter, her II-year-old brother kept whispering and diverting his sister's attention by making her laugh. This happened whenever the therapist touched on her wish to be valued by her demanding and perfectionist father, her sadness at being left to fend for herself, and her defense of being "tough." The boy's joking seemed to help his sister sustain this
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defensiveness, and probably helped him keep his favored position in the family as well. Communicating Empath» with and Fl'l'lings about a Depressed, Preoccupied Parent
I. A family consisting of two parents and three young children had undergone a series of major life crises: the father's father and the mother's two parents had been seriously ill within the last year; the father's brother had died of severe asthma, and the mother's brother had died by apparently accidental drowning; the youngest child, a boy of 8 months, was presently in the hospital with severe asthma. The mother, a constricted, dutiful person, denied that she was still preoccupied with her younger brother's death; yet, as the session progressed and she became more comfortable about talking about her feelings, she became obviously depressed and began to weep. At that point, the small 3-year-old boy began to call attention to his shoelaces with a piercing cry ("Mummy, Mummy"), as if to save his mother from her feelings by diverting her attention to himself. 2. An immigrant mother, whose 7-year-old son had a learning problem, blamed herself for not paying sufficient attention to him at the time of immigration when she was very homesick and when there was also a new baby to care for. As she described this, the boy began sucking his thumb while his smaller sister rummaged in the mother's handbag for cookies. Both children seemed to be expressing empathy for the mother and anxiety aboutlosing her attention (cookies). Communicating Feelings ofHelptessness and Compensatory Protectiveness
I. A couple, in marital therapy for six months, were both rather immature people, and so egocentrically preoccupied that they had enormous difficulty in developing any mutuality in their relationship, even in helping each other with the practiced tasks of everyday life. These problems had become vividly apparent during marital therapy, and the therapist had repeatedly pointed out that they were content with each other only when playing together as children, and never when having to behave as responsible adults. During the seventh month of therapy, they reported that their 7-year-old daughter had suddenly become afraid to leave the house to go out to play with her friends. A family session was held, during which time the child drew a picture of a royal family. A leu"ge princess was sweeping the floor with a broom in the fore-
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~round, while her parents, the kin~ and queen, who were much smaller people in the background, were not doing anything. She then added a fourth figure-intermediate in size-whom she identified as a prince, the princess's little brother. The little girl agreed with the interpretation that she was afraid to leave the house to play because she felt she had to help her parents, and that she wished for a baby brother who could be her companion. The parents subsequently reported that their daughter had become more out~oin~ since the interview. 2. A (i-year-okl girl repeatedly denied that her mother was sad, although the mother was cryin~ about her frustration, sadness, and helplessness at having to manage everything alone, without her husband's help. The child finally said, "I don't want Mommy to be sad, and she isn't!"
Communicating Fnlings of Guilt
A 7-year-old boy began worrying about the videotape cameras and wondering whether people who knew the family were watchin~ them on TV, when his mother started talking about feeling ~uilty that she had blamed him for being "bad " rather than sick. before she had realized that he was a hyperactive child and required medication. Communicating till' Identified Patient's Problem of Passive Dependence
I. A (i-year-olcl girl drew a picture of her 8-year-old brother as a female ballet dancer, dressed in pink, while her parents and the therapist were discussing her brother's babyish behavior and the ways in which the mother fostered it. Although the mother energetically denied it, the drawing confirmed this more effectively than did anything said by her husband or by the therapist. The son, who had hitherto been plaintive and infantile during the therapy session. became quieter and behaved more appropriately for his age. Although the family refused conjoint therapy, the mother continued in individual treatment, and later reported that this observation had motivated her and her husband to make some changes in their handling of the child. 2. A 6-year-old girl drew a picture in which there was a tiny girl in the distance, whom she identified as her 12-vear-old brother, and a larger person in the foreground, whom she 'id e n tified as herself. This drawing reflected the parents' perception of her being much more independent and mature than her overprotected, whiny, diabetic brother. Later in treatment , this girl drew another
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pict u rc of her brot her as a large bo y in the foreground. This reflected a substantial improvement in his independent and autonomous behavior. Communicating Feelings about Successful Family Therapy I. The 12-year-old di abetic boy mentioned a bo ve drew pictures of various objects in the office, as well as composite portraits of his parents and the therapist during the last famil y session. The famil y agreed that the drawing reflected the famil y's feeling of being in greater harmon y, as well as their difficult y in leaving the therapist, whom they wished to incorporate into their family. 2. In the mourning family previously mentioned, both children painted many pictures in black. The boy painted warlike scenes of jet fighters or destroyers, fighting battles and going down in Hames. These pictures communicated feelings of sadness mingled with anger at the d eparted stepfather, who, as it happened, was a black man. As treatment progressed, and the family dealt with their mourning, the paintings graduall y became more colorful, and the planes and boats were se n t on more peaceful missions. DISC USSION
These descriptions demonstrate somc of the many wa ys in whi ch children communicate their own feelings, and participate in defining their famil y's problems. In man y in stances, the child tries to preserve famil y homeostasis by the various behaviors which have been described. It is he who cxpresses the family's resistance to the therapist's attempts to stimulate confrontation and change. In other instances, the child acts as the primary agent of change within the famil y because his activit y disrupts the famil y's previous equilibrium. By being constantly aware that th e children, as well as adults, preserve or disrupt family homeosta sis, the therapist can integrate the child into the treatment situation in a more meaningful way. and can begin exp lo r ing the family problem to which the child is drawing attention. This is a far more empathic and effective method than to direct "Why?" and "How?" questions at a young child (e.g., "Why are you wriggling? How do you feel when momm y and daddy fight?") . Such questions usuall y increase the child's reluctance to communicate, because he himself oftcn cannot readil y use words to describe the "why" and "how" of his perceptions. His behavior, his play, and his art co nstitu te the language through which he must and can be understood, both by the therapist and by the more
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adult members of the family. Moreover, the therapist can more tactfully convey many potentially painful observations to the parents in his seemingly innocuous and aimless verbal interaction with their children (Whitaker, 19(7). To do this effectively, the therapist must constantly monitor the children's reactions, even while listening to or talking with other family members. He may not immediately draw attention to this information, but he stores it for use at some appropriate moment. Sometimes the therapist's interventions merely integrate the child into the group as a perceptive, contributing family member. Sometimes, he may wish actually to interrupt whatever else is going on, to draw attention to something the child has said or done, and to connect it with the current theme within the interview situation. Often, the child's behavior fnTIS the basis of an interpretation which draws attention to an interpersonal problem within the family. Although the use of simple toys may facilitate a child's communication, an elaborate playroom setting is certainly not a prerequisite for the emergence of behavioral clues of the kind I have described. Many of the examples which have been cited in this paper were, ill fact, observed ill a highly unlikely environment: an amphitheater in which family interviews are conducted and videotaped in front of an audience of 80 to 100 people, without any play materials at hand whatever. Nevertheless, it is more desirable and relatively easy to provide paper, crayons, building blocks, and a few simple toys, even in the setting of a private office. Aside from the more passive therapeutic stance of observing, drawing attention to, or interpreting the young child's behavior, the therapist can playa more active role. He can ask the child to draw a picture of the family, at work or at play. He can have the child take a turn in "sculpting" the family or at participating in a family game (Simon, 1972). Even then, as Ackerman (1970) has cautioned, one does well to keep one's distance at first: the child does not know the therapist and does not immediately accept a strange adult. Moreover, although active and directive methods have their place, the child's spontaneous activity is even more informative, especially at later stages in therapy when the family's relationship with the therapist is well established. It is my experience that children will rapidly become aware that their type of participation is valuable and valued by the therapist, and will quite naturally interject their comments, or will ask for appropriate play materials if they are missing at a particular session because they
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have learned to define themselves as very important members in the family. The understanding garnered from the insights of play therapy can thus be profitably combined with family therapy which is more verbally or insight-oriented. Through this technique, the young child becomes an integral part of the situation and makes his own unique, important contribution. The family therapist becomes more meaningfully committed to conjoint family therapy as the treatment of a whole system, and is more helpful to all family members in developing ways of understanding and solving their problems. SVMMARY
Family therapy, to be true to its commitment to systems theory, should be as concerned with the younger child as with all other family members, whether he is the presenting problem or not. As a rule, family therapists do not pay enough attention to the child, because to involve him requires meaningfully integrating his communications into the family svstem. Since children communicate through play, movement, ell'ld seemingly irrelevant remarks, therapists must be taught to understand and use their contributions. This paper illustrates some ways in which children's communications may be understood within a family context. Such understanding can help educate older family members regarding the children's needs and can be an important tool for meaningful therapeutic intervention in the family system.
REFERENCES ACKERMA~.:'\. W. (1~170).
Child participation in famih rlu-rupv, Fam, Proc., ~':40:{--410. B. & TAsDI. 1\1. (I~llili), Differential nxhniqucs in f.unilv interviewing' with hoth parents and preschool child. This [oumal, :):7~ 1-7:\(). KWIATKOWSKA. II. Y. (1~1l;7). Faruilv art rlu-rupv. Fam, Prot .. tl::17-",:,. StMON, R. M. (197~). Sculptin~ the familv. Fum, Pror., 11:49-57. STACIHJWtAK,.J. (;. (I ~lliH). Ps\'dlOlo~ical disturhances in children as related to disturbances in familv inll't'acrion.j. Marr. Fam .. :W: I ~:{-I ~7. TAsEM. :\1.. Al'(a:~BRAl'~. B.. & BROWN, S. L (I ~lli5). Familv ~I'OUp interviewing with the preschool child and both parents. Thisjournal, 4::nO-:HO. WHITAKER. C. A. (l~lli7). The ~rowin~ ed~e (interview). In: Trchniqurs ojFamil» Therap», ed . .J. Hale\' & L. Hoffman. :'\ew York: Basic Books. pp. ~li:)-:lfiO. Zn.BAUI,.J..I .. BER(;u .. E.. & (;ASS, C. (197~). Roll' of the youn~ child in familv therapv. In: Progress ill (;roll!J and Famil» Therap», ed. c. .J. Sa~l't' & H. S. Kaplan. :'\ew York: Brunncr/Mazcl. pp. :1H:)-:{!l~I. Al'l;ENBRAl'~.
