VIII. TREATMENT OF PARENT-CHILD RELATIONSHIPS ROSE GREEN

University o/ Southern California

attempting to discuss a present emphasis in any realm of study and I” practice, i t is important to look backward and walk, for a bit, on the well-marked road that leads toward the present scene. Otherwise, the pres- ent may seem an unrelated bit. Fortunately a long look backward is not necessary because of the very thorough and vivid portrayal of that history in Dr. Lowrey’s paper, “Evolution and Status,” given a t the 1939 meeting.’ Again, a long look backward is unnecessary because my assignment in this panel is to discuss the simultaneous treatment of parents and children and this is only one thread, albeit an important one, in child guidance clinic his tory.

The thread of clinical work with parents in relation to their children has been woven in several patterns. I n the beginning, there was a pattern of ad- vice, suggestion, and teaching-which meant manipulation of parents for the good of their child. There were problems and pitfalls in advice and per- suasion; and many parents were unwilling or unable to be moved about for the good of their child. The next step of direct psychological treatment of the parent as a person with his own problems, although not very rewarding, brought recognition of a concept which has been important ever since: the concept that a parent is a person in his own right.

The reason most parents go to a child guidance clinic is their feeling of something being wrong with a child. When the clinical team observed the child with other than the diagnostic eyes of physical, social, psychological and psychiatric study, and understood not only the factors that influenced the child’s development, but also saw that child as he was to live with, the clinic recognized there was usually something the matter with the child. This ushered in the stage of direct psychiatric treatment of the child, the detailed presentation of which has for a long time been part of the annual program of this Association.

With the great enthusiasm for direct treatment of the child, and its greater rewards than direct treatment of parents, it is a tribute to the clinical team that its work with parents maintained the importance of parents in the child’s dynamic environment. Such questions were discussed as: In whom is the focus of the trouble, the parent or the child? Which is more amenable to treatment? Because the place of the child in his family and in the clinic was better understood, development of technical skill with children outdistanced the skill with parents. With concentration of treatment effort in some cases

Trends in Therapy. THIS JOURNAL, 9: 4, 1939.

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with children, and in some cases with parents, a third grouping began to grow in size-a simultaneous approach to parents and children.

Simultaneous treatment means more than two series of interviews going an at the same time. The concept of this interaction and interrelated move- ment was presented by Almena Dawley in the Trends in Therapy program of 1939.2 I think a pattern of simultaneous clinical treatment of parents and children is now taking on more solid shape. There is a steady conviction that treating a child who lives in his own home is of little avail if a t least one of his parents is not an active participant in clinic treatment. There is a grow- ing conviction that the parent needs to be the one who refers the child, even in school clinics where first notice of a child in trouble comes from teachers.

The present emphasis, then, is built on the realization that treatment of either parent or child is not as effective as treatment of the relationship be- tween them. This means a larger area of concern than the earlier stages of development. I t requires of the clinical team a deep understanding of in- dividual personalities-child and paren ts-and of the dynamic relationship between them. I t requires a delicate skill in the use of that understanding when a new factor, clinic treatment, is called in. It requires a most detailed, albeit informal, team work of psychiatrist and social worker, which expresses this identification with the larger whole within which each works with one part.

Out of the study of the interrelated movement of parent and child come new questions concerning the parent, apart from problems within his own per- sonality, and apart from this factor as a cause of the child’s difficulty. There is exploration of a new focus upon the parent in his role of parent, and the dynamic part this can play in clinical treatment.

A theoretical elaboration of the role of parents in the family was read be- fore this Association in 1941. Paraphrasing from Dr. Allen’s paper:3 In our culture, when fathers and mothers function normally in their own roles, they Provide the essential support and direction which a child requires for his own growth.

TWO years later, a t the 1943 meeting, Katharine Wickman and Dr. Lang- ford r e p ~ r t e d : ~ “The common thing which stands out early in cases is the insecurity the parent has as a parent;” and further on (p. 233) they say:

The experience a parent may have in elaborating in detail his familial relationships, and the knowledge the worker may derive from this, is not es- sential to provide therapeutic help which is meaningful to the parent and Significant in the parent-child relationship. I n fact, the parent may always derive benefit in Some measure if the social worker and others in the clinic

t c

’ Interrelated Movement of Parent and Child in Therapy with Children. Ibid. a Dynamics of Roles as Determined in the Structure of the Family. Ibid, 12: 1,1942. ‘ The Parent i n the Children’$ P~ychiatric Clinic. Ibid, 14: 2,1944.

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have in mind a goal of helping wherever possible to increase her security as a parent.”

These contri butions-the abstract discussion of parents’ roles in the family and the syntheses out of clinical practice-help a great deal in clarifying that long obscured area of the parent’s role in a child guidance clinic.

Some acceptance of parents in the role of parents has already affected clinical practice in the steady development of certain procedures. Two I have mentioned are: the strong conviction that a t least one parent must partici- pate in clinic treatment; and the growing conviction that a parent must be the one to refer a child to the clinic. These procedures might be followed in a rather external fashion of complying with defined policies. A more signifi- cant acceptance of parents, in the role of parents, may affect clinical practice more vitally, gaining impetus and motive power throughout the process from the dynamic of what brings the parent to the clinic in the first place.

A parent comes to a child guidance clinic because he is disturbed about his child and is looking for a way to help his child. The parent may be sub- ject to all sorts of pressures-family, school, court-but it is the parent’s necessity in relation to those pressures that brings him to a child guidance clinic. The case worker’s response in feeling and active responsibility to- ward the parent’s necessity to come is an important element in the very beginning that can be utilized to enhance or to dissipate his coming in the role of parent.

I have had the privilege of reading some records of the Pasadena Child Guidance Clinic, and a bit from one of them may illustrate the above point.

The mother of an eight year old girl was in the clinic for her f i s t interview. She talked a great deal of Linda’s bed-wetting and thumb-sucking. The mother said she feared Linda had not had as much affection as she needed (many illnesses and hospitalizations); also, that she herself had had no affection and frankly expressed hostile feelings to her own mother. She resented her mother’s influence with Linda, and against herself. She felt somehow that Linda’s bed-wetting might be tied in with this conflict. Among other points of activity, the case worker helped this mother to describe and discuss the behavior that worried her. With much feeling for the mother, the worker’s activity focused clearly on the mother’s involve- ment in her relationship problems with her daughter. In all her inquiries and responses, the worker remembered that this mother had come to the clinic because of her responsibility as a parent. Toward the end of the interview, the mother was able to say she thought Linda’s behavior was retaliative: “When I lose my temper, she sucks her thumb: and when she sucks her thumb a lot, she wets the bed.”

This insight on the mother’s part is very likely the result of the worker’s acceptance of, and focus upon, the mother’s coming to the clinic in the role of parent. A different case worker might have focused on the mother’s re- sentment toward her own mother. Focus on this area as the problem would have been accepting her in the role of daughter rather than mother, and would have tended to dissipate the impetus and strength upon which this mother came to the clinic.

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Through the length of this case, March 1, 1946 to July 13, 1946, there were many comments and discussions of the grandmother, but never did the worker focus on the relationship of mother and grandmother. The worker utilized the mother’s talk in that area to stimulate discussion of the mother’s own relationship with Linda. In the several follow-ups which have come in the year and a half since clinic treatment ended, the improvement and gains in the parent-child relationship have been maintained. I think the worker’s acceptance and utilization of this woman in her role of parent was an impor- tant means of strengthening her responsibility to provide and make effec- tive the clinical treatment for her child.

Utilization of this concept of acceptance of the parent role has wide effect upon the case worker’s activity. A mother’s problem, as she presents i t to a child guidance clinic, if seen in the frame of reference of her parenthood, is necessarily seen in relation to her child-a specific problem in relation to a specific child. Another bit from the above case might illustrate this aspect of the worker’s activity. In the same first interview, the mother spoke of con- flicts about eating. When Linda did not eat properly she became ill and that worried her mother. The worke commented that she supposed that made the mother feel guilty about what she had or had not done about the eating, and that was hard for them both to bear-in different ways. Here one sees how the worker’s understanding is brought to bear upon the moth- er’s immediate problem in the relationship with her dughter.

Another illustration of the focus upon the parent-child relationship was the worker’s willingness to tell the mother something of Linda’s first visit with the psychiatrist. She was also ready to listen to the mother tell it, since Linda had talked about it with her mother. This strengthened the mother’s feeling about herself as parent. In this instance, material about the child’s interviews was used as it fitted the mother’s reflection of the movement in the parent-child relationship in the week between appointments.

The relationship between parents and children is an intimately closed one, Yet the children are in various stages of effecting some degree of emotional separation. Or they seek to live with a greater degree of emotional separation than they can deal with. A fact long recognized as important and now taking on greater significance, is that the parent, out of his responsibility as aparent, Calls into this intimate relationship the expertness of a child guidance clinic. I t is the increasing understanding and utilization of this latter part of the concept-that it is the parent who calls in the child guidance clinic a t an

in the relationship-that holds the challenge to develop increasing skill with parents.

We have a great deal to learn about the use of this knowledge in clinical practice. We must develop procedures that grow out of a deeper sensitivity to the dynamics of change in parent-child relationships. It is exciting to think of ways and means that may be found to utilize old procedures and

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many new ones that can offer the parent increasing opportunity to exercise his parental role constructively. Including the parent in treatment from the start, seeing him as the nucleus and requiring his participation in every step, is our most important means for strengthening the parent’s responsibility. Not only will this make treatment more effective, but it can be a means oi treatment itself.

Clinics are today experimenting with procedures that grow out of this approach to understanding the parent in his role of parent, and I feel confi- dent that greater skill with parents will develop, as i t did in therapy with children. Skill in relation to the use of this aspect of the parent-child rela- tionship should make more effective the clinical approach, and might shorten the average length of time for clinical treatment.

Most clinics, I think, have moved away from the feeling of blaming par- ents, whether directly or subtly, that was perhaps a natural concomitant of the first insights into the importance of parent-child relationships. The feel- ing of blame came out of an acute awareness of the importance of the par- ental role. At first we were able to use that awareness only negatively; that is, by feeling that the parent ought to be different, and in actively trying to make him so. The last decade’s exploration of the parent’s role is opening up for the clinical team a way to use that role more constructively.

It seems to me that many social institutions such as the school, court and some social agencies, are stiIl expressing blame of parents directly and in- directly. This is a negative use of the responsibility inherent in the parental role. As child guidance clinics develop further skills in this area, and develop material that reflects those skills in operation, it is hoped that a more con- structive use of the responsibility inherent in the parents’ role will become a part of the philosophy and activity of the many social institutions dealing with parent-child relationships.