the use of a consultation method in case work therapy

THE USE OF A CONSULTATION METHOD I N CASE WORK THERAPY

PAUL SLOANE, M.D. Community Health Center, Philadelphia

HE method to be discussed in this paper was developed in response to a T need for increased service that arose in the Psychiatric Clinic of the Com- munity Health Center of Philadelphia. The solution of the problem was found to lie in the use of the social worker as an auxiliary to the psychiatrist, and was arrived a t in the following manner. In going over social case records it was strik- ing to note how much insight could be obtained into patients whose productions were undirected. The material was usually very informative, and being given freely, was frequently of great psychiatric significance. Many clients eagerly sought the contact with the worker and appeared to derive a great deal of benefit from it. The worker gave encouragement, eased the tension of current situations and in general supported the client’s morale. She often seemed to win the client’s confidences even after the physician had failed. I t was felt that all of this rich psychiatric material was not being utilized adequately and that the potentialities of the relationship between the client and worker were not being fully realized. It was therefore decided to analyze the current interviews for the purpose of detecting trends in a given case. Each interview was reported in detail and discussed with the psychiatrist, who offered interpretation and suggested further procedure and avenues of approach. Since none of the workers had had practical psychiatric experience, the method had to be adapted to their needs. This led us at first to formulate the worker’s approach exclusively in terms of transference. The workers were urged to assume an attitude of expectancy and avoid any expression of their preconceptions. The need of interpretation was not stressed, the entire emphasis being placed upon the development of the positive transference. The negative transference was to be avoided since we were not seeking a deep type of therapy. Our purpose was to place the client completely a t ease and thus give him an opportunity to tell what he was striving for. Only in this way, was it felt, could we be certain of gaining his confidence and giving him enough security to work out his emotional problems. Furthermore, if suggestions were to be given on the basis of our understanding of his problems, he would be apt to accept them mwe readily.

Our success a t first encouraged us to pursue the method still further. I t was then observed that clients responded to this approach in various ways. Some showed a desire to discuss and analyze their problems frankly and without reserve. Others looked upon the worker as a punitive agent and conformed to what they thought she expected them to be. Still others exploited the worker’s kind- ness and sought to obtain all they could. The best results were naturally obtained with the first group, while with the last group an impasse was invariably reached sooner or later. It then became evident that the transference in itself was an

355

356 THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY

insufficient foundation upon which to base the therapy. It was found that the client must also gain some intellectual insight into his problems, by means of analysis and interpretation offered either by himself or the worker. In other words, where the client possessed the ability to attain intellectual insight, the transference helped to tide him over his emotional difficulties, one without the other being quite valueless. The method was thus found to have certain limitations but within these limitations it worked out fairly satisfactorily. Our experience with it, over a period of nearly 18 months, indicates that it has definite value and warrants its wider application. I t is my purpose, in the following re- port, to detail the technique of the method, analyze it and point out its indica- tions.

Method: When a case is referred, the agency record is first read by the psychiatrist. A referral conference is then held in which the case is analyzed and the possibilities of treatment considered. Cases are accepted primarily on the basis of a hopeful prognosis, as estimated by the nature of the problem, the attitude of the client and the relationship between the client and worker. The instructions to the worker are simple. No formal declaration of purpose is made to the client, unless he himself brings up the subject, since it is felt that this might increase his self-consciousness. We are guided chiefly by the patient’s need to discuss his problem with the worker. It is explained that the worker must aim to place the client a t ease and break down his resistance by the demonstration of good will and sympathy. She is advised to conduct her interviews as she has always done, but with certain modifications. Thus she must never indicate impatience or dis- approval, regardless of the provocation, nor must she show any activity in giving counsel or instituting her own plan of action without the advice of the psychiatrist. She must not contact any other member of the family. The client’s inquiries should be thrown back upon him, but as tactfully as possible in order to avoid giving the impression that the client is being snubbed. In brief, negative transference is to be avoided. It does not necessarily mean that everyone of the client’s whims must be satisfied. The worker must be prepared to help the client accom- plish things that the latter himself is unable to achieve. When a question arises as to the proper course to pursue, the client is given the benefit of the doubt. Interpretation, when offered, is done so only after consultation with the psychiatrist. It therefore follows that the client must be willing and even eager to do most of the analyzing himself.

Interviews are held a t weekly intervals and conferences with the psychiatrist after every one or two interviews. Each case is accepted for a trial period of three months, a t the expiration of which time a summary of progress is prepared. This is designed for the purpose of reorientation and formulating further plans of procedure.

It is clear from what has been said that only comparatively superficial problems can be handled in this manner. If the conflicts are too deep and arouse too much anxiety, the client will be able to utilize the worker’s aid only to a certain

CONSULTATION IN THERAPY: SLOANE 357

extent or not a t all. He may attempt to evade discussion of his real problems by emphasizing his somatic complaints, projecting his difficulties onto others, re- stricting the conversation to more or less impersonal topics or making repeated requests for material assistance. These are all recognized forms of resistance and unless the resistance can be overcome the chances of effecting any appreciable change remain minimal. We realize that this problem may frequently arise because we do not acquaint the client with the purposes of treatment, but since no attempt is made to meet the problem on a deep therapy level we are content to let the client direct the interviews in his own way a t first. If, after a time, no progress is made, it may be necessary to bring up the question of treatment formally and inquire what the worker’s visits mean to the client. Treatment may be interpreted as a means of understanding the patient’s drives and draining off emotional tension by free discussion of his problems. In addition, the real sources of anxiety may be approached by interpreting the patient’s resistances to him; or the anxiety may be increased by withholding a certain amount of assistance.

If these methods do not succeed it may be decided to discontinue treatment. In all cases the progress can best be determined by evaluating the state of the relationship between the worker and client a t any given time. Everything is directed towards perfecting the positive transference, guiding its development and overcoming resistances, since this is the essential factor of the method. In favorable cases treatment is continued until the client himself expresses a desire to terminate the contact, or until he feels that he is able to assume the responsibility of working out his problems further.

Selection of Cases: Cases are usually accepted because the conflicted client reveals the need to discuss his intimate problems with the-worker. It is only under this condition that the client may be expected to cooperate and accept responsibility in working towards a solution. In order to avoid losing too much time and and energy, accurate diagnosis is essential. Emphhsis is placed upon the ability of the client to shoulder his guilt feelings and face them squarely. The suitability of a case for treatment can oftentimes be determined by merely,reading the record, but the final decision is not made until the referral conference.

Some workers are able to discern psyciatric problems in their clients and planfully steer them to the psychiatrist; others work with difficult cases blindly and, after exhausting every other means, finally thrust them upon the psychiatrist. I t is therefore important to know what the reason for referral is. Most of the cases accepted deal with problems within the family group, the patients usually ex- pressing profound dissatisfaction with themselves and their adjustment. Patients presenting definite psychiatric syndromes are occasionally accepted, although on the whole it is recognized that they require the more thorough individual study of the psychiatrist. Here too we have been guided by the patient’s dependence on the worker. We have frequently been misled by the client’s apparent devotion to the worker, only to find out later that he was merely exploiting the latter. It is not difficult to detect these patients within a short time, however.


Results: In favorable cases a change in the content of the interviews was usually observed at the very start. The interviews began to take on definite form and direction. The material brought out was of much greater emotional significance than formerly and historical facts relevant to the current conflicts were now freely given. In addition, the client himself seemed to direct the interviews, observe their continuity and work out his emotional problems as they arose, without demanding any more assistance from the worker than her moral support. Progress was determined by development of positive transference, relief of tension within the home, usually after a temporary increase of tension, and dis- appearance of somatic complaints. The upgrade was characterized by a more hopeful, positive attitude on the part of the patient.

In one case, a widow developed a hysterical reaction shortly after her husband’s death and felt that she could not remarry because of a sense of guilt in regard to her husband. As a result of treatment she was able to lose her guilt feeling and concomitantly her hysterical symptoms. She then began to consider remarriage as a normal outlet. Another woman whose pride was wounded when her husband deserted her, transferred her bitterness towards her child who sub- sequently became a behavior problem. As she was able to realize the projection of her attitude onto the boy during the course of treatment her handling of the situation changed, with the result that the boy’s behavior improved almost at once. She could then recognize the futility of longing for her husband and began to seek other outlets. In one case, a woman, tied to an inferior man to whom she was apparently ensldved by her passion, was finally able to overcome her physical feelings for him and provide an outlet for her idealistic strivings by devoting herself to her children. One widow who felt that her two children stood in the way of her remarriage, asked to have them placed but tried to put the responsibility upon the worker. In the course of the treatment she was able to recognize the fact that she rejected the children and was merely using the question of marriage as a pretext to get rid of them. Her feeling of guilt about her rejection finally led her to decide to keep the children and devote herself to their welfare. In one instance of manic-depressive psychosis, the contact with the worker enabled the patient to obtain sufficient moral support to enter a mental institution, with the result that a definite amelioration of her condition took place.

This is the nature of results obtained. In other cases, where the client was unable to cooperate or where the worker did not follow instructions, treatment had to be terminated. The average period of treatment varied from a few months to over a year.

How the Method Works: It will be at once recognized that the worker’s approach in this method is not remarkably different from the usual approach in other cases. How account then for the difference in results obtained from that of the ordinary worker-client relationship ? From the remarks of patients it becomes evident that their willingness to discuss their problems depends largely upon their feeling


that the worker is sympathetic and that they have a t least one friend to whom they can turn. What is it in the worker’s attitude which impresses them? In the first place the worker visits a t regular intervals and thus indicates her interest. The latter, not having the need to be defensive, begins to lose his reserve and goes into a free discussion of his conflicts and experiences which have a high emotional significance but which have been inhibited until now. He now permits himself to reveal the inner meaning of these experiences, thus facilitating self- analysis. Some clients have stated that the idea of giving way to physical symptoms, which they realized arose from emotional causes, was abhorrent because it was obviously an escape. Others have admitted that they had tried to abolish certain thoughts from their minds in the hope of avoiding anxiety but the dis- carded thoughts always managed to return to haunt them. Now, supported by the worker’s interest and the hope of getting well, they have decided to face their fears squarely. The worker, on the other hand, finds that as the material is analyzed her interest in the case increases and she becomes more attentive to details and innuendoes which might otherwise have been overlooked.

The method works well with the type of patient who is sufficiently disturbed about his personal problems to question his own motives, whose conscience does not permit hin to rest in peace and who needs the approval and guidance of one in authority. The mere presence of such an authoritative person, if a t all forbear- ing, is often sufficient to release a stream of confidences. The client sees in the worker one who provides relief and has the power to be generous or depriving, to accept or reject, approve or disapprove. The worker is the personification of the client’s conscience, around which the patient’s drives mold themselves of their own potential force. As the case unfolds itself, it is therefore natural for the worker to become invested with an emotional aura, subject to hate, suspicion and boundless affection. The patient begins to-realize that his attitude consists largely of rationalization which never really satisfies him and which he inwardly despises. The function of the worker then becomes that of exposing the patient’s subterfuges and helping to remove the props of his defenses one by one until he is brought face to face with his basic motives in all their nakedness, the prin- ciple, of course, being that the patient’s attitude will shift unswervingly from one position to the next towards the ultimate goal of reality. It is therefore essential that the worker be made aware of the patient’s attitude both toward the environ- ment and the worker at any given moment so that rapport may be maintained and the next step anticipated. This is probably the most important function the psychiatrist has. During this process the transference situation serves to give the client an opportunity to work off some of his hostile feeling and thus afford him the moral support and courage to carry on and begin to think of fulfilling old aspirations. The type of patient least amenable to this form of treatment is obviously the infantile, self-centered individual, who refuses to accept any responsibility and throws himself entirely upon the mercy of the worker. Such a person is apt to be self-satisfied and demanding. He projects the blame onto everyone


else, is never content and feels that the entire world mistreats him. He demands consideration from others but is unwilling to make any sacrifices himself. In brief, he is the individual who has always felt himself to be rejected and reacts by insisting that the world owes him a living. Such a person is usually so insecure that he does not take kindly to frankness or objectivity on the part of the worker, interpreting everything as rejection. Any attempt on the part of the worker to have the client discuss his problems is taken as an unfriendly act. Since the worker aims to be passive, the client tends to exploit her, using the positive transference as a means of obtaining material needs and avoiding discussion of his problems. By his demands he attempts to avoid anxiety, i.e. he constantly seeks evidences of the worker’s devotion. This type of individual appears to develop a positive transference all too readily. Actually such a transference is largely negative since it is heavily tinged with insecurity, suspicion and fear of rejection. One may summarize by saying that the type of individual who can profit most from this type of approach is the one who has a strong ego and is sufficiently stable to question his motives without too much fear of rejection. Between this type and the insecure, narcissistic individual who requires constant reassurance, there is any number of variations in the degree of stability. It is the diagnosis of this factor which is most important in the selection of cases.

Improvement may be attributed to the fact that as the patient gains insight into his mechanisms he is able to assimilate his newly found knowledge in adapt- ing himself to reality. This of course implies that he has also undergone a series of emotional reactions, characterized by fear of the worker’s condemnation and reassurance that his behavior will not be followed by rejection. The transition stage on the road to improvement is manifested by actual changes in his external relationships which, until a proper balance has been struck, may appear unreason- able and disturbing. The process of working through really consists of ironing out the discrepancies between the instinctual demands and the exigencies of reality, in other words, correlating the newly interpreted material with existing external conditions by a method of trial and error. The fact that the material is conscious renders it easily assimilable. The patient must possess a certain degree of courage to deal with his emotional problems and it is therefore clear that the weak infantile ego will be unable to achieve such a goal. This process has been pointed out in another connection by Alexander.

Aduuntuges: The method has enabled us to handle many more cases than we could ordinarily. In addition, we have found that we could treat a wider range of patients, since many of them refuse to visit a psychiatrist. The reasons for this vary. For instance, many women object to being treated by a man, because of their sexual fantasies. Others feel that a visit to a psychiatrist reflects upon their mental soundness. Frequently after a physical examination the Psychiatrist will tell the patient that there is nothing seriously wrong but that he is a bit nervous. Patients often resent being told that their symptoms are of nervous origin, interpreting such comment to imply the unreality and insincerity of their com-


plaints. Furthermore, if too much anxiety in regard to emotional problems is present, any approach which threatens to uncover these factors may be rejected. I t is a fallacy frequently held, despite all evidence to the contrary, that one must be a psychiatrist in order to obtain significant material from a patient. A disturbed patient will usually talk freely to anyone who is sympathetic and helpful. I t is true that the psychiatrist may be able to utilize special skills in developing the transference, but it is equally true that clients commonly warm up to social workers very quickly, probably because of their dependence on them for relief. Some patients actually express their preference for the worker, stating that they get more help from her.

The method has furthermore proved itself to be adapted to those social workers who have had little or no practical psychiatric experience. It is explained to the worker who is hesitant about her role that she need be no more than a sympathetic listener and a good reporter. In this respect the method has several self- checking features. For instance, failure of a case to show progress may be due to some bias or undue activity on the part of the worker. This can be detected and in conference the case worker helped to understand it and given suggestions on how to handle it. It may be said parenthetically in this connection that no attempt is ever made to delve into the worker’s personal life. As difficulties arise the approach may be modified and cases can thus be kept from being carried interminably, when it becomes evident that they hold forth no promise of success.

The use of the method has thrown much light upon the principles of case work therapy and has shown us its limitations. By realizing that certain cases will never be suited for purposes of therapy and that they can best be handled super- ficially, much time and energy can be spared and the work of the agency made more efficient. This orientation can frequently be made a t the referral conference, before the consultation service has been initiated.

The training offered to the worker is invaluable. She may have some qualms about handling psychiatric material a t first, but as she comes to realize that not too much is required of her and that the bulk of the responsibility is being as- sumed by the psychiatrist, she begins to gain a sense of security. She knows that she can always fall back on the latter for guidance and reassurance whenever she feels uncertain. As the case unfolds before her eyes, it becomes a fascinating study full of potentialities which increase her zest in the work. She begins to think intelligently and planfully about all of her cases. She is no longer content to work blindly, but insists on knowing what the possibilities of treatment in any given case are and whether she should not conserve her efforts for the more hopeful type of material.

the use of a consultation method in case work therapy

Documents