COLLABORATIVE PSYCHIATRIC THERAPY OF PARENT-CHILD PROBLEMS*

STANISLAUS SZUREK, M.D., ADELAIDE JOHNSON, M.D., EUGENE FALSTEIN, M.D. Institute for Yuvenile Research, Chicago

HIS paper describes a technique for psychiatric treatment and research in T the behavior problems and psychoneurotic disorders of children in which concomitant therapeutic efforts are made by two psychiatrists, one of whom deals with the significant parent and the other directly with the child. Although the rationale of the approach has been indicated by Lowrey (I) , and a t times even explicitly stated in the literature by Almena Dawley (2), Greig (3), Anna Freud (4), Silberpfennig (5), and Rogers ( 6 ) , people who are clearly aware of the importance of the parental neuroses in the treatment of children, it seems that the type of procedure which has been elaborated in this clinic might be of interest to record, not only because of its therapeutic value, but also because of its re- search possibilities. *

There is an increasing awareness on the part of clinicians dealing with children that the behavior of a child is to be understood fundamentally only in the con- text of the intrafamilial interpersonal relations. Pathological relationships be- tween mother and father and child play a great role in helping to maintain the distorted and unintegrated tendencies in the child.

It is unnecessary here to refer to the many, years of excellent and successful collaborative work that has been done with the psychiatric social worker seeing the mother and the psychiatrist seeing the child in treatment disorders that are not too firmly crystallized. Such collaborations between psychiatrist and social worker will continue to constitute the predominant method of treatment in a child guidance clinic (7). This paper deals exclusively with those severely dis- torted child-parent relationships where the techniques of two psychiatrists well trained in dynamic psychiatry seem to be necessary for alleviation of the present- ing problems.

Because it had been impossible to treat severe school phobias by treatment of the child alone,' in this clinic the mother, or the more significant parent, and the child were each treated by a psychiatrist concomitantly and, as it seemed, more successfully (8). Such collaborative therapy has been expanded in treating many behavior problems and other severe neuroses. Experience over a period of about three years with this technique has led the writers to the impression that.: ( I )

many severe cases cannot be treated at all without the use of it; (2) it becomes a valuable tool in carrying research further in the study of interpersonal relations; and (3) many cases, where child or mother might be successfully treated alone, still seem to progress more rapidly when the two are treated concomitantly.

'Presented at the 1942 Meeting. 1 The one child reported in School Phobia (8), who had not returned to school was one whose

mother had not been treated. Four months after the mother came into treatment he went back to school.

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Probably the most fundamental requirement of such therapy is that the com- petitiveness of the psychiatrists involved in treatment shall be at a minimum. A psychiatrist treating the .mother, for example, with unconscious rivalrous at- titudes toward the other therapist, may quite unwittingly block the mother’s expression of jealousy and hostility toward the child’s therapist. Such complica- tions can become manifold. A competitive therapist may unconsciously fail to give all of his available information to the other therapist for discreet use, or may ignore as superfluous what the other therapist could make available to him. Thorough training may reduce the problem, but a long training in dynamic psy- chiatry may not entirely resolve the sources of these competitions.

The writers do not draw too sharp a line between the neuroses and behavior problems, but there are certain quantitative distinguishing characteristics. The provocative or self-frustrating activities of the child with the behavior disorder seem to stem from the fact that there has been less warmth and support in the environment, and therefore less guilt about his greater tendency to direct seeking of gratification of impulses in an ungenerous and unsympagetic milieu (9).

In addition, there appears to be in these children as much wish to punish the hostile environment as to punish themselves, if not more. The self-punishing ele- ment has usually been more stressed in the literature. Because of these considera- tions it is difficult a t times to know what is the more basic motive in the pro- vocative behavior of such a child. Sometimes, the psychiatrist working alone with the child, sees only the child’s guilt, anxiety and resentment, and not the prov- ocation from the parent. Two psychiatrists in such a situation can observe better than one how mutually gratifying to all involved is the particular mode of interpersonal behavior, no matter how distorted or disguised the symptom or technique may be. I t is as inaccurate to say that the mother alone fosters the behavior in the child, as to say that the child on his own stimulates certain re- sponses in the mother. I t is a mutual exchange, built of techniques slowly evolved between them. A few brief examples follow.

Elaine, IQ 150, a middle child with two brothers, in a very moralistic, respect- able family, a t age 12 suddenly began stealing and revealed to her mother that she had had intercourse many times with a high school boy. The mother was horrified and brought the child for treatment. I t soon became obvious that this behavior was in defiance of and designed to injure the mother. The child’only became guilty and depressed after she became aware of her mother’s reactions. The mother, in treatment a t the same time, gradually became aware of impulses and attitudes toward the child that were thoroughly hostile and designed to provoke situations where Elaine would be confronted with some impasse. She had no such feelings toward the sons, but was over-identified with the daughter who was named after her. Elaine was in treatment a brief time and was relieved of anxiety and depression, whereas the mother continued for a long period. No further difficulty arose with Elaine. The mother saw how she pushed the child into the father’s lap, so to speak, and then reacted to the child with intense jealousy. She recalled episodes in her own early life of an attachment to her

SZUREK, JOHNSON, FALSTEIN 513

father about which she had great guilt and she was fearful of seeing the same reaction develop in Elaine. At the same time, however, by unconsciously foster- ing such an attitude in Elaine, she derived vicarious gratification of her own unintegrated infantile impulses.

Another mother, whose boy was extremely sadistic toward her, revealed with tears during her treatment that she had derived real gratification from his having twisted and hurt her arm. She wondered why she had permitted him to do it. Her own masochistic tendencies led her unconsciously to foster sadism in her son.

In this clinic, collaboration between psychiatrists in treating so-called be- havior problems and neuroses has raised a number of significant hints about the matter of “choice of symptom.” This term implies too much of conscious volition. The symptom itself is an on-going process expressing interplay of un- conscious tendencies. How does a child, and later an adult, happen on a certain type of behavior such as stealing books or fire setting, or tearing the clothes, or promiscuity? How does a child evolve enuresis, vomiting, or a reading inhibition as one symptom of his neurotic disorder? In the following instance it was pos- sible to see that one factor directing the child’s expression of her tensions was the specific neurotic anxiety of the mother.

Doris, 13, suddenly set the family apartment on fire. The child had never destroyed with fire before, although she enjoyed bonfires very much. When the mother came into treatment, she revealed with considerable anxiety the deep hostility between her and Doris, an exact repetition of the rage existing between the mother and her sister after whom Doris was named. Three weeks before the fire setting the mother told her own therapist that she had gone to a fire several blocks away. While a t the fire she thought, “My own apartment will be the next to burn and Doris will be the one to start the fire.” The mother went home and told Doris and her father about it, saying children had set the fire, although of this she was not a t all sure. On the day she heard that her apartment was on fire she knew instantly that Doris was responsible. Also, when she came into treat- ment she was horrified by the fact that ever since the fire she had had the firm conviction that Doris would be struck by an automobile. The violent feelings felt by this woman toward her own mother and sister were projected onto Doris and unconsciously the mother fostered the acting out of her own frightening, forbidden feelings which dealt with years of hostile death wishes against her family by burning. For a few days before Doris set the fire, the mother had been extremely hostile and provocative, as she later told her therapist.

Another example in a family studied in detail was David’s mother who “had a horror of a stealing child.” In handling David she was vacillating and uncer- tain when it came to advising him firmly of property rights. Further discussion with the mother gradually revealed her own early stealing tendencies, the con- flict about which had not been resolved.

In another family James promptly became a party to an interesting reaction manifest in his mother during his and her treatment. The mother said in discuss- ing her own problems that she “could not stand bedwetting in a child.” A week

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later she returned and reported that for the first time in his life 13 year old James had wet the bed four nights in a row.

These symptoms or pathological techniques become complicated when several family members are involved. For example, in the case of Marion who was extremely provocative with her mother it was found that the father fostered much of the child’s acting out because of the vicarious gratification he derived from seeing his wife injured.

The behavior of parent and child in relation to their two therapists is illus- trated by a brief incident in the treatmen,t of Robert and his mother. Robert had almost recovered from his school phobia when suddenly he became much worse and his mother called the boy’s male therapist. H e a t once referred the mother to her own therapist, a woman, and in the following interviews it became quite clear that the mother’s need to see the boy’s male therapist was in part an expres- sion of her own unresolved oedipal conflicts. I t was obvious that she provoked Robert, making him much worse, and thus felt she now had sufficient excuse to talk to Robert’s therapist herself. This was one of numerous efforts on her part not to work through her own difficulties with her therapist but to “seek advice” from the boy’s therapist.

On the basis of 22 cases studied in detail and illustrated by these brief excerpts it seems clear that in some instances the parent unconsciously gives the child a cue. I t may be an expression of a specific fear, as in the fire setting case, or an ambivalent anxious reaction to some behavior or symptom of the child. This com- bination of events has seemed to fix the form of the clinical picture through which the parent’s own unintegrated and forbidden impulses are afforded vicarious gratification.

Although it is frequently easier to see the forbidden impulse vicariously fos- tered by the significant adult in the behavior problems, there are also strong hints of the presence of the same factors in the more disguised pathologic formations of the neuroses.

We have had occasion to study several sets of identical twins, which material will be reported in greater detail in a later communication. In these studies one could see the mother, and at times the father, splitting off their acceptable ten- dencies from the forbidden. They fostered the unacceptable trends in one twin and the acceptable in the other. One mother brought her normal boy for treat- ment and for a long period was protective and secretive about the really sick boy who represented for her gratification of certain tendencies in herself which she had great difficulty in facing and giving up.

Since its reactions are gratifying somehow to the parent, the child is not brought for treatment until the secondary gains or gratifications of the child exceed those of the mother or father, when the latter speaks of complaints. At that time, too, the excess is usually sufficient to cause anxiety in the parent to bring the child for treatment but not to accept treatment for himself. Getting the parent into treatment depends upon such factors as the skill o[ the therapist, and the anxiety of and gratification to the parent.

From the experience of this clinic impressions concerning treatment of be-

SZUREK, JOHNSON, FALSTEIN 5’5

havior problems and neuroses differ somewhat. These impressions may be sum- marized as follows.

I. Almost no serious behavior problem regardless of the child’s age can be treated unless the significant parent is in treatment. 2. Any serious neurotic adjustment between parent and child necessitates the treatment of both parent and child with the following possible exceptions: a) an adolescent neurotic child, not too bound by the parent, can often be successfully treated without treatment of the parent, if the child is old enought to be able possibly to identify with the therapist toward a satisfactory emancipation; b) treatment of the parent alone with a child under 4 or 5 may be satisfactory; c) intensive treatment of the child of 5 or under, suffering from a neurosis of recent origin, may be sufficient occa- sionally. Levy (10) has reported the successful treatment of this type of conflict.

The logical outcome of such collaborative experiences is that it would seem better in treatment to avoid, on the whole, giving much in the way of advice. The educability of parents bringing children as disturbed as are seen in this clinic is rather limited. In other words, it is not suggested that a mother “show more restraint” or “give more love,” for she would have done this if she could have, and she may regard the advice as criticism. I t does little good to urge a parent to give a stealing child an allowance without understanding the parent’s own deeper attitudes about giving and stealing. For instance, Mrs. A. clearly indicated as her treatment progressed that although she had given Ted an al- lowance according to earlier advice of a therapist, she deeply envied the boy and begrudged him his allowance. The boy sensed her attitude and stopped steal- ing only when her own conflicts over envies had been resolved.

Often out of anxiety or hostility, parents may become very demanding for concrete advice. The skillful therapist will see beyond this device and deal with the anxiety back of the demand. For the same reason it is not very helpful in training the young social worker or beginning psychiatrist to “advise” that they never give advice to demanding, hostile parents. In other words, the young therapist must deal with his own feelings in the situation and do the best he can. Even the experienced psychiatrist a t times finds himself giving advice. He may tell parents he can do no more for their boy until they relax their pressure on the child for achievement, but the psychiatrist soon finds he has only shifted reponsibility and has not done therapy. Parents, out of guilt, may try to lighten their pressure, but the child senses the artificiality and anxiety, and feels less assurance as to where he stands. Through some measure of reliving early un- resolved conflicts with their permissive therapist the hostility beneath the anxi- ety in the parents is lessened with the gaining of some insight.

Workers interested in the socially delinquent child have had some hope that these collaborative psychiatric techniques would be effective in treatment. It is apparent that such children, in very little conflict with their social group, possess adefect in conscience with regard to the larger community. Such children cannot develop guilt and self-restraint in relationship to the larger community without much more warmth and firmness than can be offered in the weekly psychiatric interviews. At times these aims can be attained by the warm, consistently firm

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and basically friendly foster-parent with whom the child lives, or in the institu- tion properly staffed for such treatment, such as Aichhorn’s. As for getting the parents of the child in for collaborative treatment they usually are unavailable for the same reasons as apply to the child, i.e., they usually cannot be won by the brief psychiatric interview.

In conclusion, it would seem that a collaborative approach by two psychiatrists is frequently necessary and more rapidly effective in treatment of most behavior problems and the more severe neuroses. It is recognized that facilities for such studies are sometimes not available. But beyond the clinical advantages, and really of more fundamental importance, are the research opportunities made possible by this direct participant observation of the dynamic interplay between parent and child. Out of such observations have come rather clear impressions that the unconscious gratifications parents derive from their unintegrated ten- dencies, is a powerful stimulus in fostering certain behavior or determining a neurotic symptom in a child. I t is apparent that for the complete study of the genetics of so-called “symptom choice” or pathologic formations in children, one must know the meaning of such manifestations to the parent. Such collaborative techniques make it possible to observe something of the genesis of behavior and, eventually, of character traits.

It seems this method permits direct empirical observations bearing on these questions instead of depending upon speculations and reconstructions from studies of adult neurotics or from the study of the neurotic child alone. It affords a further avenue of inquiry before retreating to such concepts as “constitutional tendencies.”

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I . LOWREY, LAWSON G. Trends i n iherapy: evoluiion, staius and irends. AM. J. ORTHO-

2. DAWLEY, ALMENA. Trends in iherapy: inter-related movemeni of pareni and child in

3. GREIG, AGNES BRUCE. The problem of the pareni i n child analysis. Psychiatry, 111:

4. FREUD, ANNA. Technic of child analysis. Nerv. & Ment. Dis. Pub. Co., New York,

5 . SILBERPFENNIG, JUDITH. Mother types encountered in child guidance clinics. AM. J.

6. ROGERS, CARL. The clinical ireatrnent of the problem child. Houghton Mifflin Com-

7. SZUREK, S. A. Some problems of collaborative iherapy. A.A.P.S.W. News Letter IX:

8. JOHNSON, ADELAIDE, FALSTEIN, E. I., SZUREK, S. A,, and SVENDSEN, MARGARET.

9. SZUREK, S. A. Notes on ihe genesis of psychopathic personality trends. Psychiatry,

10. LEVY, DAVID. Release therapy. AM. J. ORTHOPSYCHIATRY, Ix: 4, 1939.

PSYCHIATRY, Ix: 4, 1939.

iherapy with children. Ibid.

(1944, P. 539, 1940.

1928.

ORTHOPSYCHIATRY, XI: 3, 1941.

pany, New York, 1939.

1940, P. 1.

Schoolphobia. AM. J. ORTHOPSYCHIATRY, XI: 4, 1941.

v: I , p. I , 1942.