ارشاد الأزمات انجليزي
ارشاد الأزمات انجليزي
ارشاد الأزمات انجليزي
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Page i
Crisis Counseling
A Contemporary Approach
Second Edition
Ellen H. Janosik
Page ii
Page iii
CONTENTS
Preface
viii
Part One
Crisis Theory
1
Nature of Crisis: Recognizing the Signs
Etiology of Crisis
Chronology of Crisis
Summary
15
References
16
2
Parameters of Crisis: Defining the Limits
17
Classification of Crises
18
19
20
22
Intervention Techniques
29
32
Summary
38
References
39
3
Analyses of Crisis: Expanding the Framework
Systems Theory and Crisis
41
41
42
44
45
46
50
Summary
57
References
61
Page iv
4
Categories of Crisis: Choosing an Approach
63
Developmental Crises
64
Situational Crises
67
Compound Crises
67
Application Principles
70
Summary
83
References
84
Part Two
Individuals in Crisis
85
5
Children in Crisis: The Early Years
87
Attachment
88
Family as a Resource
102
Counseling Children
103
Summary
106
References
106
6
Adolescents in Crisis: The Teen Years
109
Attachment
109
Temperament
111
Cognitive Development
111
Moral Judgment
113
Somatic Changes
116
Sexuality in Adolescence
117
Identity
126
Summary
References
7
Adults in Crisis: The Early Years
133
133
137
139
Behavior Patterns
140
Decision Crises
141
Career Choices
150
Parenthood Issues
153
Working Mothers
155
159
Summary
162
References
163
8
Adults in Crisis: The Middle Years
165
Effects on Children
167
Loyalty Issues
168
Divorce Mediation
170
Page v
171
Family Tasks
174
Joint Custody
176
179
179
Remarriage
183
Adoptive Parents
191
Post-parental Issues
193
Counseling Adults
194
Summary
196
References
197
9
Adults in Crisis: The Later Years
199
Adaptation to Aging
202
Retirement Crises
203
206
Relocation Crises
210
Caregivers' Dilemma
212
Types of Facilities
216
Loss Crises
223
226
230
Summary
233
References
234
Part Three
Families in Crisis
237
10
Marginal Families in Crisis: Illness and Disability
239
Marginality in Families
240
245
256
260
Summary
263
References
264
11
Disorganized Families in Crisis: Child Abuse
265
Abuse Targets
267
Abusers' Traits
268
270
277
282
Summary
286
References
286
Page vi
12
Disorganized Families in Crisis: Spouse Abuse
289
291
294
Theoretical Explanations
295
Violent Wives
299
300
301
Summary
309
References
310
Part Four
Groups in Crisis
313
13
315
Communities in Crisis: Disasters and Unemployment
Epidemiology of Community Crisis
316
317
Disaster Classifications
318
319
Economic Disasters
330
Summary
340
References
341
14
Society in Crisis: AIDS and HIV
343
AIDS Parameters
345
HIV-positive Individuals
347
348
351
353
355
356
358
359
360
361
363
Summary
367
References
368
Part Five
Atypical Crisis
371
15
Post-traumatic Stress Reactions: War and Rape
373
Page vii
375
A Three-factor Theory
377
384
387
389
390
391
393
Summary
397
References
398
16
Multiple Trauma: Victims, Families, and Caregivers
401
Trauma as Crisis
403
410
417
419
423
Summary
429
References
429
Part Six
Crisis Program Planning
431
17
Crisis Programs: Collaboration and Diversification
433
434
435
Interdisciplinary Collaboration
436
438
439
440
Peer Counseling
440
Training Programs
441
442
444
Summary
446
References
447
Index
448
Page viii
PREFACE
The nature and extent of contemporary crises have altered in the last few
years, and that alteration is the impetus for this second edition of Crisis
Counseling: A Contemporary Approach. The appeal of the first edition
depended, in part, on its timeliness and its relevance to modern life. During the
last few years, vast changes have taken place throughout the world, and
change rarely ushers in a halcyon interlude. Instead, people living in the latter
part of the twentieth century must confront long-standing problems and
complex new problems. As always, the four horsemen of the apocalypse-war,
famine, disease, and death-still ride among us. Inevitably, there are crises that
disrupt whole nations, crises that disable communities, and crises that disturb
individuals and their families.
Like the first edition, this book is intended for care providers from various
disciplines, such as medicine, nursing, social work, psychology, and counseling,
who endeavor to help people deal with the conflicts and demands of modern
life. Crisis intervention is not limited to members of the health professions.
Therefore, this book should also be useful to teachers, managers, and
members of the clergy who are often called upon to be crisis workers, even
when this is not part of their job descriptions.
The basic premise of this edition is unchanged, namely that crisis work consists
of the systemic application of tested principles to situations in which the
equilibrium of an individual, family, or group is seriously impaired. Some care
providers believe that crisis intervention is inappropriate for persons already
suffering physical or psychiatric disability. However, the disequilibrium
attributable to crisis is often superimposed on long-term disability or
impairment. In such circumstances, crisis intervention can be an appropriate
and effective treatment modality.
There is no way to avoid crisis entirely, either in one's own life or in the lives of
others. This means that everyone has, at one time or another, experienced
crisis. It also means that virtually everyone, regardless of role or occupation,
has been called upon to act as a crisis counselor. Crises are so recurrent and so
universal that they are indeed part of the human
Page ix
Page x
tence that the client in crisis should not be regarded in isolation but rather as
part of a social gestalt. This means that the external and internal causes of
crisis are significant, and that client and context should be assessed. Although
specificity in crisis work requires greater theoretical knowledge and clinical
expertise, this approach does not negate the basic principles of crisis
counseling. This edition should enable thoughtful practitioners to engage in
active, time-limited crisis work based on psychological, physiological, and
sociocultural connections between the crisis event and the responses of the
participants.
At one time, certain principles were considered appropriate for all crisis events.
Crisis workers now try to include in their assessment not only the
characteristics of the crisis, but also the characteristics of the persons involved.
In earlier publications, it was stated that only the circumstances or nature of
the crisis should be addressed. This book, however, advocates a
comprehensive approach that assesses the crisis, the people in crisis, and their
reciprocal interactions.
ELLEN H. JANOSIK
Page 1
PART ONE
CRISIS THEORY
Page 3
1
Nature of Crisis:
Recognizing the Signs
Humanity transcends nationality. We're human beings before we are anything else.
John Hume
Page 4
tion and equilibrium are regained, but the resolution of the problematic event
may or may not be in the best interests of the individual or family.
Crisis theory and intervention are chiefly concerned with the recognition,
assessment, and management of the critical event and the crisis experience. In
order to appreciate the range and limits of crisis theory, it is necessary to
define certain terms precisely. A hazard consists of any event that endangers
the adaptation or adjustment of an individual, family, or community. Hazardous
events may come in the form of interpersonal change such as loss of a
significant person through death or divorce. They may also take the form of
social change, such as the loss of a meaningful role due to retirement. The
hazardous event may consist of changes in the environment such as moving to
a new home or facing a natural disaster. Physiological changes arising from
illness, aging, or disability are other types of hazardous events that have the
potential to generate crisis. Examples of various hazardous events are shown in
Table 1-1.
There is widespread belief that certain life events are inherently more stressful
than others, and therefore are more likely to precipitate a crisis. It is difficult to
measure the effects of a hazardous life event in numerical terms, although
Holmes and Rahe (1967) endeavored to do so. Their formulations have been
widely circulated. Other researchers have found an association between a large
number of stressful life experiences and the subsequent incidence of chronic
illness. Wilder and Plutchik (1985) expressed doubtfulness on the merits of
quantifying hazardous life events
TABLE 1-1 Classification and Examples of Hazardous Life Events
Classification
Examples
Significant developmental
Becoming a teenager
milestones
Entering college
Leaving home
Getting married
Becoming a parent
Significant decisions
Changing careers
Divorcing
Remarrying
Relocating
Retiring
Significant challenge and change Experiencing illness
Suffering
an economic
accident
Confronting
reverses
Facing disaster or
catastrophe
Page 5
when they noted that one cannot measure the impact of life events in terms of
physical dimensions, such as numbers, decibels, or volts. In every person a
complex process mediates between any event and the individual's response to
it. This mediation process influences the emotional reaction to the event, the
cognitive interpretation of it, and behavioral activities that may or may not be
adaptive. In crisis counseling, as in most forms of psychotherapy, it is more
useful to explore the mediation process that is operating than to assign
numerical quotas to hazardous events.
Our interpretation of events and our responses are influenced by our previous
history, by our personality structure, and by whatever resources are available
to us. The impact of a series of hazardous events is likely to be cumulative.
Many challenging events might be manageable if they arrived singly or
infrequently, but they can prove overwhelming when they occur within a short
period of time. This presents a powerful argument for deferring decisions or
avoiding additional changes in one's life in the aftermath of any critical event.
In dealing with hazardous events and with the rigors of daily life, most people
tend to adopt a fairly consistent pattern. This is because they cling to
behaviors that have worked well for them in the past. Some individuals and
families can use a wide spectrum of coping behaviors, while others limit
themselves to a paltry few. Members of the latter group are more prone to
crisis and require outside help. At the same time, even competent, resourceful
people may find themselves in crisis and be unable to solve their own
problems.
Psychological deficits and psychiatric disorders, in and of themselves, do not
constitute crisis but they may intensify vulnerability by curtailing coping
behavior. For our purposes, coping behavior refers to the psychological and
psychosocial processes used by individuals and families to maintain or restore
equilibrium or balance. Coping behaviors encompass, but are not restricted to,
the defense mechanisms; they include both internal (psychological) and
external (psychosocial) behaviors that people employ.
All individuals have a breaking point at which they become disorganized and
dysfunctional due to certain situations. However, the threshold of the breaking
point varies greatly, even among people caught up in the same experience. For
some capable individuals and families, the breaking point is seldom reached,
even in very difficult circumstances. Such people have an armamentarium of
coping skills that enables them to handle challenging events with confidence
and resourcefulness. Even for the most competent person, however, there may
be times when customary solutions prove inadequate. Old problem-solving
methods fail and new ones do not seem readily available. As a result, the
failure to cope sets the stage for the turmoil that is characteristic of crisis.
Page 6
testing.
Reality testing is the ability to differentiate external stimuli from internal stimuli.
Persons capable of reality testing can make distinctions between what is
happening around them, and thoughts and feelings generated within
themselves. Therefore, their responses and interpreta-
Page 7
tions are largely based on what is taking place in the real world. As a result,
their reactions to events are more or less rational and appropriate. Reality
testing is a term borrowed from psychodynamic theory; it can be used to
explain the emotional, cognitive, and behavioral errors characteristic of persons
in crisis. Anna Freud (1953) formulated a list of defense mechanisms,
explaining that people use a variety of protective or defensive measures, some
of which are more functional than others. Some major defense mechanisms are
as follows:
Repression. The inability to remember or be consciously aware of material or
content that is unacceptable to the individual. For example, a person who
cannot acknowledge hostility toward a relative may "forget" the relative's
birthday.
Displacement. The transfer of emotion from one target to another. A man who
is angry with his wife may control his feelings at home but yell at his office
secretary.
Reaction formation. The transformation of unacceptable feelings into behavior
indicating opposite emotions. A mother who is excessively loving and
conscientious may, at a deeper level, feel angry and frustrated by her family's
demands.
Isolation. The separation of an idea from its emotional component. A college
student may dismiss feelings of homesickness but often think of family reunion.
Undoing. An effort to cancel or retract certain actions, real or imagined.
Undoing may be attempted through apology, atonement, or ritualistic behavior.
The classic example is Lady Macbeth who could not wash the blood from her
hands despite repeated, ritualistic cleansing.
Rationalization. The formation of reasonable explanations that may or may not
be true, for certain actions. It helps individuals conceal their actual motives
from themselves and others. An example is the alcoholic who says he needs to
drink because his job is so high pressured.
Intellectualization. This resembles rationalization but is more subtle. It involves
the use of intellectual processes to avoid emotional involvement. A couple may
substitute intellectual discussion for open disclosure of their feelings about one
another.
Page 8
crisis.
The cognitive distortion inherent in crisis means that the power to assess a
situation, to plan effectively, and to predict consequences is greatly reduced. A
person in crisis is distracted, incoherent, and often irritable. Extreme emotional
reactions cause cognitive errors, and the
Page 9
Figure 1-1
Chronology of Crisis
cognitive deficits heighten emotional reactivity. Some individuals deal with their
distress through withdrawal or regressive behaviors. One form of regressive
behavior is belief that problems will be solved without effort or that a
miraculous rescuer will appear on the horizon. Occasionally, an individual's
distress takes the form of physical symptoms such as insomnia or anorexia.
Because emotional reactivity represents a root cause of crisis, it is advisable for
a crisis counselor to permit a certain amount of emotional discharge or
catharsis. This may encourage regressive tendencies if it is unduly prolonged.
Therefore, the extent of emotional catharsis should be time limited and
carefully monitored. Following this, attention should be directed to correcting
cognitive distortions. By correcting cognitive errors, counselors encourage the
restoration of reality testing and emotional control.
People in crisis are seldom able to make a rational connection between a
precipitating situation or event, the subjective distress that followed, and their
eventual disequilibrium. Therefore, the counselor should make connections.
The actual dimensions of the crisis must be outlined before a solution can be
found. As far as possible, an individual's sense of helplessness, hopelessness,
and entrapment should be alleviated. Only when the situation is reduced to
manageable proportions for the individual can cognitive and emotional
distortions be corrected. The counselor should be prepared to deal with the
individual's initial defensiveness and unwillingness to grapple with the problem.
Here again the correction of cognitive errors helps lower defensiveness and
makes the individual more willing to see the true proportions of the problem.
Cognitive distortion is a global term but its manifestations and its
consequences are quite specific. The irrational thinking that accompanies
cognitive distortion can be identified in the illogical, self-defeating
Page 10
Page 11
How people interpret a situation determines their reaction to it. For example,
people who believe themselves in danger react defensively or aggressively to
protect themselves.
How people interpret a situation influences emotional reactions. Situations that
seem overwhelming evoke strong emotions.
Crisis is characterized by distortions leading to dysfunctional behavior:
Angry, resentful people adopt fight tactics.
Frightened, anxious people adopt flight tactics.
Page 12
admitted to a psychiatric hospital. The news upset Trudy so much that she became
hysterical, and canceled the plans to spend a fall weekend in the country with
George. This outing had been eagerly anticipated by them both.
Page 13
In the days that followed, Trudy did not regain her composure. The news of her
mother's breakdown reminded Trudy of her mother's illness after a spontaneous
miscarriage that had occurred when Trudy was ten or eleven years old. At that time
her mother had been seriously depressed. She was hospitalized briefly, medicated,
but remained apathetic and withdrawn for months afterward. Turning inward,
Trudy's mother took no interest in her family. Conditions in the home deteriorated
so much that Trudy's grandmother moved in to care for the children and the
household. Her mother's illness lasted for months only, but her grandmother
remained in the home for two years. She was an efficient manager, but she was
strict with the children, especially Trudy. She constantly exhorted them to be quiet,
to help with chores, and never, never worry or upset their mother.
Trudy's reaction to her mother's illness was excessive and disproportionate. She felt
guilty for feeling happy in her new life when her mother was undoubtedly lonely.
Even though her father reassured her by phone that her mother was making
progress, Trudy began to torment herself with the fixed idea that her mother would
never get well. Every phone call from Phoenix alarmed her more; she insisted that
her father spoke of her mother's recovery merely to keep Trudy from worrying.
Trudy's pessimism about her mother's illness increased and she began to blame
herself for causing her mother's illness, saying, "She got sick because I was selfish
enough to leave home. And she won't get well until I return."
Trudy's concerned husband promised that they would both go home at Christmas
time, and this calmed her for a few days. Then she began to say that she could not
wait for Christmas because her mother might be dead by then, and they would
never see each other again. Her anxiety mounted until she was unable to continue
working, even though the lost income meant that they might not be able to afford
the Christmas visit. By this time Trudy was spending most of her time staring into
space and was always on the verge of tears. She had no interest in taking care of
the apartment of which she had been so proud. George tried to be understanding
but every day he became more frightened and bewildered by Trudy's behavior. He
urged Trudy to call her mother directly and see for herself that her mother was
recovering. His suggestions were unheeded. On one occasion she told George that it
didn't matter whether they visited Phoenix at Christmas because by then she and
her mother would both be dead. At this point George made an appointment for
Trudy to see a therapist at an Army mental health facility, and escorted her there.
The opinion of the Army psychologist assigned to Trudy was that she was
experiencing a situational reaction that had precipitated crisis. She had been happy
in her marriage and had adjusted well to living so far from her parents. Trudy was
meticulous and compulsive in discharging her responsibilities to people she loved.
Her distress on hearing of her mother's illness brought back memories of the difficult
period in her childhood
Page 14
when she felt abandoned by her mother and relegated to the stern care of her
grandmother. In Trudy's worry about her mother she projected her childhood
feelings of abandonment onto her mother. As a child she longed for the return of her
mother; as a young adult she remembered this early disquiet and assumed that her
mother was experiencing the same misery.
Trudy rejected the accurate reports from her father. She was told daily that her
mother was improving. On one level she was aware that her own state of health
was excellent, yet all she could dwell on was the great distance separating the two
of them. Her regressive behavior consisted of ruminating endlessly about her
situation, rejecting reassurance, and sabotaging her husband's efforts to arrange a
Christmas reunion.
The therapist saw the couple together in one session, saw Trudy alone several
times, and arranged for a final session with both partners. He helped Trudy
understand that separating from her parents and beginning a new life with George
was a legitimate task. There was no reason to burden herself with feelings of guilt
or disloyalty, nor to assume that she was responsible for her mother's psychiatric
problems, now or in the past. Through the aegis of Army Relief, arrangements were
made for Trudy to travel to Phoenix a week before Christmas, and for George to join
her for the holiday. As soon as travel plans were made, Trudy decided to return to
work in order to buy gifts for her family. The therapist asked Trudy to check in with
him once after she returned and let him know how the visit went.
Critical Guidelines
The therapist did not directly address Trudy's emotional, cognitive, and behavioral
distortions, yet all intervention aimed at reducing her erratic and unrealistic
responses to her mother's illness. The therapist did not delve into Trudy's lingering
resentment of her mother's early illness. Instead, the therapist focused on the hereand-now aspects of her reactions to the current illness. The importance of the
marital bond was reinforced by emphasizing George's unfailing support. Trudy's use
of projection was discouraged by questioning her belief that she caused her
mother's present hospitalization. Her accomplishments as a wife and homemaker
were acknowledged, but fantasies of her omnipotence in causing her mother's
symptoms were discounted.
The therapist working with Trudy was well aware of her obsessive personality and
her use of a primitive defense mechanism such as projection. However, he was
impressed with her history of good adjustment during successive life stages. By
recognizing her overall social stability and her commitment to her marriage, the
therapist was able to establish a therapeutic alliance that enabled her to manage
the conflict between her obligations as a wife and as a daughter (Frieswyk et al.,
1986). The therapist's suggestion that Trudy see him at least once after visiting her
parents would provide additional data about Trudy's ability to mediate between
internal distortion and external reality.
Page 15
The thrust of crisis intervention for Trudy was her need and her right to accomplish
the developmental tasks of a young adult (Budman & Stone, 1983). This approach
enabled the therapist to describe Trudy's predicament as an impediment to the
normal developmental progression to which she was entitled. There were hysterical
and histrionic aspects to Trudy's behavior, and manipulative components as well.
Repeated allusions to the developmental theme promoted clarification and
acceptance by Trudy and her husband, and discouraged their fears of
psychopathology. McKenzie (1988) believes that brief intervention is more effective
when focal themes are kept in the foreground. This promotes adjustment to the
current life situation.
Summary
This introductory chapter describes the emotional, cognitive, and behavioral
distortions that compose the disequilibrium of individuals in crisis. The crisis
counselor is urged to adopt an approach that deals with the triad of distortions.
The social environment and the support systems available to an individual are
important in the development and in the effective resolution of any crisis.
Immediate relief of the distress and disorganization characteristic of crisis is
more important than exploring historical causes. Although the disorganization
experienced by persons in crisis challenges the counselor, it also makes people
more amenable to therapeutic suggestions about coping abilities.
Reality testing is an adaptive ego function that enables people to distinguish
inner and outer stimuli. Impaired reality testing is an aspect of crisis that
impedes problem solving. Restored reality testing follows the correction of
distortions that prevent people in crisis from perceiving their actual situation.
Sometimes people in crisis are really afraid that they are going crazy. If this
happens, the crisis counselor may indicate that many others in a similar
situation might feel the same way, and that the individual's distress is
understandable. Cognitive and behavioral improvement are unlikely to occur
until the counselor provides opportunity for the client to express strong
emotion. This emotional catharsis should be monitored, but it usually makes
the person in crisis more receptive to measures designed to alter dysfunctional
thoughts and actions. There are two major goals in crisis counseling. The goals
are interdependent. One goal is to modify any distortions that are operating;
the second goal is to ease internal distress to facilitate problem solving.
The clinical illustration described various emotional, cognitive, and behavioral
Page 16
References
Budman S.H., and J. Stone. ''Advances in Brief Psychotherapy, A Review of
Recent Literature." Hospital and Community Psychiatry 34(1983): 939-946.
Caplan, G. Principles of Preventive Psychiatry New York: Basic Books, 1964.
Freud, A. The Ego and Mechanisms of Defense. New York: International
Universities Press, 1953.
Frieswyk, S.H., J.G. Allen, D.B. Colsen, et al. "Therapeutic Alliance: Its Place as
a Process and Outcome Variable in Dynamic Psychotherapy Research." Journal
of Consulting and Clinical Psychology 54(1986): 32-38.
Holmes, T.H., and R.H. Rahe. "The Social Readjustment Rating Scale." Journal
of Psychosomatic Research 2(1967): 213.
Horowitz, M.J., C. Marmar, J. Krupnick, et al. Personality Styles and Brief
Psychotherapy. New York: Guilford Press, 1984.
Lindemann, E. "Symptomatology and Management of Acute Grief." American
Journal of Psychiatry 101(1944): 141-148.
McKenzie, K.R. "Recent Developments in Brief Psychotherapy." Hospital and
Community Psychiatry 39(1988): 742-752.
Sullivan, H.S. The Interpersonal Theory of Psychiatry. New York: Norton, 1953.
Wilder, J.F., and R. Plutchik. "Stress and Psychiatry." In Comprehensive
Textbook of Psychiatry, 4th ed., edited by H.I. Kaplan and B.J. Sadock.
Baltimore: Williams & Wilkins, 1985.
Page 17
2
Parameters of Crisis:
Defining the Limits
Mishaps are like knives that either serve us or cut us as we grasp the blade or the
handle.
James Russell Lowell
Page 18
Page 19
Page 20
opportunity offered by the crisis. In choosing the second course of action, the
addict merely substitutes one addictive behavior for another. The third course
is the most maladaptive, since the addict compounds the crisis by moving
wholly outside the law. In some ways the addict's recourse to an act of
Page 21
armed robbery to
obtain money for a
new supplier and is
arrested.
solution: coping
skills are impaired
and crisis
worsens.
Page 22
with the problem. Often the failure of attempted coping behavior activates
memories of earlier failures, all of which add to feelings of disquiet. It is not the
hazardous event that causes crisis, but the event coupled with inability to
cope. The insoluble nature of the hazardous event is compounded by feelings
of entrapment. Despite their best efforts, people find themselves in situations
that are beyond them, and the disparity between external demands and the
resources of the individual or group may be quite painful.
Crisis, in many respects, is less compelling than emergency, which is immediate
and unforeseen. Entering school, marrying, or changing jobs do not constitute
emergencies but may bring challenges that lead to crisis. Some clinicians
believe that an emergency exists if immediate intervention is warranted. If the
person in distress can wait twenty-four hours, a crisis is present rather than an
emergency. It is possible for an emergency to be superimposed on a crisis. An
example of this is an individual who has been trying to deal with a critical
situation and becomes so discouraged that he is seriously suicidal. Usually a
crisis represents a situation that has been building up over time. Unlike
emergencies, which tend to respond to almost any remedial measure, crises
require a search for alternative ways of coping, and collaborative problem
solving. In the previous example, the suicide risk can be considered an
emergency that demands immediate attention. Even after the suicide risk has
abated, the critical situation remains and must be resolved. Table 2-3
illustrates the sequence that occurs when an emergency is transformed into a
crisis.
Grief and Crisis
Differences between normal grief and its less normal counterpart, depression,
have been noted. Neither grief nor depression is a pleasant experience, but the
latter is more pathological. One feature common to both experiential states is
that they are reactions to loss, either real or symbolic. Precursors of grief are
often apparent and therefore more identifiable than precursors of depression.
As a rule, grief is a reaction to the sustained loss or absence of any person or
object that is highly valued. Thus the grief of a mother for a lost child, of an
athlete for an unattained trophy, or a student for the security of home and
parents have much in common. In grieving, all people mourn the loss of
something meaningful; thus people who grieve are those who have learned to
love, to form attachments, and to acquire values and identifications.
Page 23
Emergency (r)
Shock
Disbelief
Distress
Panic
Hope
Compliance
Gratitude
Stage II
"Uncanny"
Shame
emotions
Awe
Guilt
Fear
Anger
Dread
Helplessness
Hopelessness
Focal awareness
Selective
inattention
Crisis (r)
Bewilderment
Confusion
Noncompliance
Confrontation
Conflict
Chaos
Continued
Page 24
TABLE 2-3 Continued
Stage III
Reintegration
Change
Collaboration
Problem solving
Anticipatory guidance
Alternatives
Consensual validation
Source: Adapted from Sullivan (1953), Lindemann (1944), and Caplan (1964)
Page 25
others may be a profound deprivation for the client. A minor facial scar,
imperceptible to observers, may engender deep depression in an adolescent
but cause only mild regret in a housewife. Loss of autonomy, loss of function,
or loss of role may cause grief reactions in some individuals and pervasive
depression in others. What then is the difference between the two experiential
states, either of which may be precipitated by loss?
Rubin (1981) stated that the central task after losing a loved one is the
loosening of emotional ties to the beloved. This task of object detachment
follows a predictable sequence. The acute grief reaction lasts from three to
twelve weeks, after which mourning may continue for a period of one to two
years. At the end of this longer period, detachment from the loved one is
thought to be concluded. Persistent and intense grieving beyond this time is
assumed to indicate incomplete relinquishment of the loved one. The
distinction between normal grieving and depression is based on the functioning
level of the bereaved and the length of time that has elapsed since the loss.
This conceptualization agrees with the psychoanalytic definition of mourning as
a reaction to the loss of the beloved and a process of gradual detachment
(Freud, 1953).
The work of Lindemann (1944) indicated that there were patterned grief
responses after the death of a loved one. When a tragic nightclub fire in
Boston brought death and injury to many young people celebrating a football
victory, Lindemann, who was then working at Massachusetts General Hospital,
interviewed a number of survivors and relatives of persons killed or injured. He
found that overcoming the loss of a loved one depended on meaningful grief
work, the purpose of which was the disengagement of the griever from the
deceased, followed by readjustment and the ability to form new interpersonal
relationships. The implications of this extensive investigation were that
experiences of loss are difficult for everyone, but become crises for persons
who are particularly vulnerable because of earlier life experiences, personality
attributes, or both.
Lindemann's theoretical constructs on loss and grief work have proved durable
and have been incorporated into many crisis intervention programs. A few
years after the nightclub fire, Lindemann established the Human Relations
Center in Wellesley, Massachusetts, which became a model community mental
health center. By providing crisis intervention to persons confronting hazardous
Page 26
Page 27
Belief that grief has a beginning and an end is prevalent among health care
professionals. Many investigators have postulated various stages of grief,
generally consisting of shock, despair, guilt, withdrawal, acceptance, and
adjustment. Engel (1964) identified normal grieving as having three stages:
1. Shock and disbelief as denial is used.
2. Awareness and recognition as denial fails.
3. Ritualization and restitution.
There is also belief that when acute grief lasts beyond a few months, chronicity
develops due to failure of the detachment process. Silverman and Worden
(1992) noted that young children who lost a parent devoted considerable
energy to staying connected to the deceased. They did this through dreams,
by speaking of the dead parent, thinking of the dead parent, or by preserving
keepsakes that belonged to the dead parent. These behaviors were interpreted
by the investigators either as efforts to keep the dead parent alive or to make
the loss seem real. Such efforts to maintain a connection have sometimes been
labeled dysfunctional and problematic. Dietrich and Shabad (1989) have
stressed the need to disengage from the lost one. Other experts disagree,
noting that while the parent died, the relationship did not (Siegel et al., 1990).
Similar attempts to preserve connections have been observed in parents after
the death of a child. Preoccupation with the deceased expressed by talking
about the deceased, by reminiscing, and by valuing mementoes may help
grief-stricken adults and children adjust to a new social context. This is a
process crucial to the normal grief and mourning task (Worden, 1991).
For crisis counselors, the period of acute grief has the greatest impact but
prolonged or chronic mourning is also significant. For some individuals the crisis
of grief is not resolved once and for all. It may seem dormant, but it is always
present and available to be reactivated later in ways that may generate or
intensify another crisis. The phenomenon in which the anniversary of a loss
revives earlier grief is all too familiar. Thus, related crises may occur periodically
even after a loss seems to have been successfully worked through. Neither
acute grief nor chronic mourning is always dispelled permanently.
The value of sequential stages of grief and mourning is that observed behaviors
can be identified and described. Baker et al. (1992) claimed that stage or
phase conceptualizations are oversimplified and are of little clinical value.
Instead, they offer a series of time-specific tasks that must be achieved. Early
phase tasks begin as soon as the individual learns of the death. This phase
includes an understanding of what has happened and the use of any protective
or defensive mechanisms that guard against the psychological impact of the
loss. Middle phase tasks include working
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through the loss and the pain it brings. Late stage tasks include reintegration
of identity and resumption of age-appropriate developmental tasks. Although
the subjects in this study were children, the tasks to be accomplished in each
stage are applicable to adults also. Clinical interventions can be tied to the
stage of grief the mourner is experiencing. This task-oriented model interprets
grieving behaviors as adaptive rather than pathological. Table 2-4 describes
the stage-specific tasks of grieving presented by Baker et al.
There is some value in knowing stages of grief, but more important is
awareness that differences between normal and abnormal grieving are
differences of intensity and not differences of kind. Grief work is painful but
indispensable if the crisis of loss is to be resolved. Among the interesting
speculations on this topic is the idea that prolonged depression may be a
defense against active grieving, since grief work demands painful awareness of
loss before restitution can begin.
Identification of crisis stages emerged from clinical observation of individuals
and families reacting to disability or bereavement. Although the reactive stages
presented by various theoreticians are not always congruent, there are
overlapping areas of agreement. Expressions of grief may be individualistic,
but, in general, early responses to crisis tend to be defensive. The first impact
of crisis due to loss or change activates protective maneuvers, which may take
the form of stereotyped or automatic behaviors. The mother of a boy killed in a
motorcycle accident will finish the family laundry as if the act of completing
ordinary work refutes the fact of the loss. Families whose household effects are
destroyed by fire or flood may react numbly, drawing comfort from possession
of a single
TABLE 2-4 Phase/Stage-Specific Grief Tasks
Phase/Stage
Significant Tasks
Early grief Understand that someone has died.
Relate the implications to oneself.
Engage in protective acts toward self and family
members.
Middle grief Acknowledge reality of the loss.
Accept emotional reaction to the loss.
Explore and reevaluate the lost relationship.
Confront the pain caused by the loss.
Late grief Restore sense of selfhood and identity.
Resume age-appropriate developmental tasks.
Invest
in new
relationships.
Cope with
periodic
resurgence of pain.
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Figure 2-1
Comparison of Normal and Abnormal Grief
Page 30
expressed by those seeking help. Even in the first therapeutic encounter the
counselor must try to mobilize and channel any available resources.
Unless the counselor explores the symbolic meaning of the critical event, it is
difficult to understand the intensity of reactions that are being displayed.
Frequently, the symbolic meaning of the crisis far outweighs reality. A family
man passed over for promotion may in his disappointment discount his
impressive accomplishments and feel totally worthless. A depressed mood
follows that threatens his family life and his job performance. A college
freshman far from home may develop sudden physical symptoms that make
leaving school acceptable to the student and the family. An elderly woman may
suffer a period of disorientation after moving to a new neighborhood. In each
case the response to the situation seems excessive until the symbolic meaning
is understood. Even after exploring the meaning of the precipitating event and
clarifying its dimensions, the subjective experience of the client should be
considered valid. The counselor's assessment should include the amount of
confusion and disorganization present, any angry or aggressive impulses
toward the self or others, the presence or absence of external supports, and
indications of internal strengths.
Crisis counselors should first guide individuals and families toward mastery of
whatever immediate circumstances are causing the most distress. Although
some emotional expression is allowable, it is advisable even in early sessions to
call attention to extreme or irrational feelings on the grounds that these
interfere with problem solving. Behavioral distortions should also be
questioned, not only the client's behavior, but also the client's interpretation of
the behavior of others. Emphasis on rational thinking and on sound reality
testing are ongoing. Reducing the immediate turmoil is a prerequisite for
problem solving.
In crisis counseling, services should be flexible and accessible, but the primary
focus is the crisis situation. The contract for crisis treatment is usually short
term, extending no longer than the duration of the crisis. During counseling
sessions, which may vary in length from fifteen minutes to an hour, the crisis
worker is actively involved but not excessively directive. Although the active
stance of the crisis worker may incline clients toward dependency, the
dependency is negated by the short-term nature of the relationship.
Sometimes crisis contracts are open ended, but the majority are limited to six
or eight sessions. An excellent rule for the crisis worker is to avoid making
decisions for clients and to restrict interventions to what clients are unable to
do without help. Restored functioning and resolution of the crisis through
expanded coping behavior is sought. A minimum goal of crisis work is to
maintain precrisis levels of functioning. A more ambitious goal is to improve
precrisis levels of functioning.
Frequency of meetings is a decision made primarily by the crisis worker. If
distress is extreme or, if there is a question of self-destructive-
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than eight to ten weeks. After that length of time there will be subtle changes
in the interactions between counselor and client; interventions can no longer
be classified as crisis work. If referrals for additional therapy are indicated,
these should be made after the original crisis has subsided and equilibrium has
been restored.
Crisis intervention is a circumscribed, time-limited approach; it is a brief but
relatively intense modality whose purposes are clearly defined. Termination
may sometimes seem premature to clients and even to crisis counselors, but
the temporary nature of acute crisis demands adherence to
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individuals facing crisis are better equipped if they have an idea of what may
lie ahead. Increasingly the docile, submissive patient is recognized by health
professionals as a person who may have a relatively difficult adjustment to
illness. More demanding patients who ask insistent questions about their
condition and seek information about proposed treatments frequently achieve a
better adjustment than do patients who
Page 33
family system. More often than not it is the family system in which the crisis
developed and in which it must be resolved. After the dimensions of the crisis
have been noted, and various distortions identified, the client and the crisis
counselor jointly develop a plan of action. Here the crisis counselor may be as
active as necessary, but no more so. Suggestions may be made, but coercive
direction is inadvisable. Solutions must be acceptable to the family and not just
to the crisis
Page 34
counselor. One of the most valuable services a crisis counselor can provide is to
instill hope within distraught people. Since every crisis inevitably comes to an
end, this assurance can be given without reservation.
Throughout the intervention process, attention is paid to whatever strengths
and abilities the individual and family possess. Preoccupation with defeat and
failure dampens hope. This does not mean that reassurance should be
unrealistic, nor should the crisis counselor try to dispel all anxiety. Some
anxiety can propel the client toward adaptive problem solving, provided anxiety
does not become overwhelming.
Even though secondary prevention involves persons who are already in crisis,
group and community programs can be used to their advantage. Parents
Anonymous is a group program for actual and potential child abusers.
Gamblers Anonymous is a group program for compulsive gamblers trying to
overcome the habit. These programs resemble Alcoholics Anonymous, which
combines group support with a structured format. Pregnant teenagers
comprise another population that is often the recipient of secondary
prevention. For this population the most effective programs offer primary and
tertiary prevention, in addition to secondary measures needed during the
immediate crisis of labor and delivery. Postnatal counseling concerning
sexuality, contraception, parenting, and education fall under the rubric of
primary and secondary crisis prevention.
Tertiary Crisis Prevention
Tertiary crisis prevention endeavors to reduce any residual impairment that
may result from a poorly resolved crisis. Since the thrust of crisis work is to
improve functioning rather than personality change, it is possible to educate
persons outside the health professions to the need for primary and tertiary
intervention and to involve them to a considerable degree. Teachers, scout
leaders, and athletic coaches are examples of people who can learn to identify
and help persons embarked on a crisis course. These informal care providers
can also help individuals who have recently moved from a crisis state to
restored homeostasis. If community agents are sensitized through training
programs, the media, or ongoing communication with health professionals,
they can become important adjuncts in crisis prevention.
Clinical Example: Stage-Related Intervention for a Grief Reaction
For weeks Harriet and Phil had looked forward to attending their fifth college
reunion. The morning of their departure they drove to Phil's parents, who had
agreed to care for their two-year-old
Page 35
child, Anabel. On the way their small car collided with a truck and was demolished.
Harriet and the child suffered minor injuries; Phil was seriously hurt and was
pronounced dead on arrival at the local hospital. Harriet reacted quietly when told
of Phil's death. Her child and Phil's parents were very distraught, but Harriet was
able to comfort and console them to some extent in the hours after the accident.
Some observers commented on the flat, automatic aspect of Harriet's behavior. On
an intellectual level she was aware that Phil was gone but her emotions seemed
frozen. She made most of the funeral arrangements with the help of other family
members, and expressed strong desires to have the kind of funeral "Phil would have
wanted."
At the grave site, Harriet lost her composure for the first time. She became agitated
and hysterical, screaming violently and throwing herself across her husband's coffin.
Relatives pulled her away as she wept and shouted, "No, no-you must come back to
me." Harriet had chosen not to have her child come to the cemetery so Anabel did
not witness her mother's outburst. By the time the funeral group returned home
Harriet was quieter, although she seemed remote and unresponsive to those who
expressed their sympathy. The next day she stayed in her room, leaving Anabel in
the care of a friend. She spent most of her time in the lounge chair Phil had loved.
Dry eyed, she talked about feeling responsible for Phil's death because she had
wanted so much to attend the reunion. Her anger was directed toward herself and
even toward Anabel. She seemed resentful when well-meaning sympathizers
reminded her that she still had a child to live for.
For about a week Harriet refused to leave the bedroom she had shared with Phil.
She took no interest in her appearance nor in the grief that Anabel and Phil's
parents felt. Harriet's sister became worried by this behavior and consulted the
pastor who had officiated at the funeral. It was he who suggested that grief
counseling might be helpful.
Critical Guidelines
Because Harriet had no psychiatric history and because her husband's tragic death
was so recent, crisis intervention was considered the treatment of choice. In dealing
with Harriet, the crisis counselor formulated interventions related to the early tasks
of grief resolution. Harriet's initial tasks included gaining an understanding of what
had happened and overcoming her feelings of personal responsibility for Phil's
death. Until the funeral she had been numbed by what had happened and she was
able to deny her loss by comforting family members who shared her loss. Only at
the cemetery, when her husband's body was lowered into the ground, did Harriet
realize the permanence of her loss. She felt ashamed of her histrionic behavior and
resolved not to lose control again. Her retreat to her room was an attempt to
remain composed by avoiding any references to Phil's death. Instead of drawing
Page 36
isolated herself. She was angry with herself, with Anabel, and with Phil's parents
because they were alive and he was not.
Harriet's inability to cry and her unstated resentment of Anabel concerned the
counselor. Her intense anger and her guilt for feeling angry frightened Harriet. She
was afraid that if she gave way to grief, these bewildering feelings would become
obvious to everyone. Counseling sessions dealt with Harriet's mixed feelings of love
and rage at supportive family members. She was assured that such feelings were
not unusual, that grief work was hard and painful, and that her inability or
unwillingness to weep and accept sympathy were adding to her trauma. In the
safety of counseling sessions Harriet was able to acknowledge her loss by crying
and by verbalizing her conflicted feelings. The counselor encouraged Harriet not to
withdraw from others, but to share her need for help. Her dealings with Anabel were
especially destructive because Harriet had distanced herself from her daughter
when the child was already feeling deprived and abandoned.
Before terminating the therapeutic contract with Harriet, the counselor invited
Anabel and Phil's parents to the last session. Here the emphasis was on reuniting
the family, on remembering the deceased, and on sharing memories. Although grief
counseling was provided for only two months, Harriet was functioning at a more
normal level. She was given the option of joining a support group for the recently
widowed but had not yet made a decision.
Studies of bereavement indicate that grief-related pain may persist for years after a
loss, especially if the death was sudden and tragic. No precise point has been
established for full recovery from grief. Time may be a healer but it is not always a
predictable element. It is the process or the way in which people handle grief rather
than the duration that is most significant. In times of mourning prompt crisis
counseling helps people understand their feelings and integrate the loss into their
life experience.
Harriet's indecision to join a support group immediately was understandable in light
of her grief stage. Instead of turning away from family members she had learned to
turn toward them. After a loss like hers it is not unusual for family members to
become dependent on one another for understanding and relief. In time Harriet will
become less preoccupied with her grief and more willing to establish relationships
with other people. Through counseling Harriet was able to reach out to her
daughter, whose suffering was as great as her own. The loss of a parent activates
great fear in children, who often feel they may be abandoned by the surviving
parent. Even though Anabel was tenderly cared for by relatives, she needed to hear
from her mother that she is cherished and will not be abandoned. The plight of
Anabel was aggravated by her mother's behavior and inability to look beyond her
own grief.
It is normal for people who have suffered loss to withdraw to some extent, but not
totally or for long periods of time. One of the most common signs of a worrisome
grief reaction is stoicism,
Page 37
or the failure to cry or express sadness about the death. Extreme regression and
apparent refusal to display grief, even with trusted friends or family members, are
signals that crisis intervention may be necessary.
Critical Guidelines
The goal set for Joel's mother was to help her recognize the death of her son, to
experience the pain of permanent loss, and to
Page 38
immerse herself in active grieving for a time. Only then would she to able to
complete the detachment process. The well-meant protection of her family was
interpreted as an influence that helped perpetuate her denial. In addition, the
subterfuge of the family contributed to her accurate conviction that important
information was being withheld from her.
A time-limited crisis model was used to facilitate grief work for Joel's mother. All the
adult members of the Benson family were invited to a series of six weekly meetings
coordinated by a crisis worker. At these sessions Joel's death was discussed frankly
and openly. Family members explained their motives for not being candid with Joel's
mother and admitted that their decision was ill advised. During the meetings the
family talked and wept together. Joel's widow talked about the bitterness she felt
toward her husband, even though she grieved for him. Joel's brother described the
battered body of his brother and his own lonely ordeal of going to the city morgue
to identify the corpse. The sixth meeting of the series was attended by the entire
family, including Joel's children. Encouraged by the crisis worker, the family
arranged to meet at the cemetery on a sunny day. Together they planted flowers on
the grave as Joel's mother began the painful work of acknowledgment, detachment,
and restitution.
Summary
Crisis should not be confused with stress and emergency situations, neither of
which contains the growth potential of crisis resolution. The disequilibrium
characteristic of crisis may lead to productive outcomes, such as improved
coping ability and less dysfunction. In formulating crisis theory, the
contributions of Lindemann (1944) and Caplan (1964), among others,
emphasize the usefulness of crisis intervention, and its applicability in primary,
secondary, and tertiary preventive models. Generic crisis work is relevant for
individuals, families, and communities who are in a temporary state of
disequilibrium. It is an intense, timelimited modality directed to the resolution
of a particular problem or situation.
Crisis theory has enhanced our understanding of grief and mourning as
necessary and adaptive reactions to loss. Several theorists have proposed
sequential models of grief reactions but many are merely descriptive. Recent
studies offer task-related stages of grief. Stage-related tasks indicate the
readiness of mourners to accomplish grief work and move on. Clinical
interventions can then be presented that are compatible with the stage of task
accomplishment that the mourners are experiencing.
Page 39
References
Baker, J.E., M.A. Sedney, and E. Gross. ''Psychological Tasks for Bereaved
Children." American Journal of Orthopsychiatry 62(1992): 105-116.
Bowlby, J. "Attachment." In Attachment and Loss, vol. I. New York: Basic
Books, 1969.
___. "Separation." In Attachment and Loss, vol. II. New York: Basic Books,
1973.
___. "Loss." In Attachment and Loss, vol. III. New York: Basic Books, 1980.
Caplan, G. Principles of Community Psychiatry New York: Basic Books, 1964.
Dietrich, D.R., and P.C. Shabad The Problem of Loss and Mourning. Madison,
Connecticut International Universities Press, 1989.
Duvall, E.M. Marriage and Family Development, 5th ed. Philadelphia:
Lippincott, 1977.
Engel, G.H. "Grief and Grieving." American Journal of Nursing 64(1964): 9398.
Erikson, E.H. Childhood and Society. New York: Norton, 1963.
Freud, S. Mourning and Melancholia, Complete Works, vol. 14. London:
Hogarth and the Institute of Psychoanalysis, 1953.
Lindemann, E. "Symptomology and Management of Acute Grief." American
Journal of Psychiatry 101(1944): 141-148.
Maslow, A. Toward a Psychology of Being New York: Van Nostrand 1962.
McCartney, K., and A. Galanopoulos. "Child Care and Attachment: A New
Frontier the Second Time Around." American Journal of Orthopsychiatry
58(1988): 16-24.
Murphy, S.A. "Mental Distress and Recovery in a High Risk Bereavement
Sample Three Years After Untimely Death." Nursing Research 37(1988): 3035.
Phillips, D., K. McCartney, S. Scarr, and C. Howes. "Child Care Quality and
Children's Social Development." Developmental Psychology 23(1987): 537-
543.
Rubin, S. "A Two Track Model of Bereavement: Theory and Application in
Research." American Journal of Orthopsychiatry 51(1981): 101-109.
Selye, H. The Stress of Life. New York: McGraw-Hill, 1956.
Siegel, K., V.H. Raveis, B. Bettes, et al. "Perceptions of Parental Competence
While Facing the Death of a Spouse." American Journal of Orthopsychiatry
64(1990): 567-576.
Silverman, P.R., and J.W. Worden. "Children's Reactions in the Early Months
After the Death of a Parent." American Journal of Orthopsychiatry 62(1992):
93-104.
Sullivan, H.S. The Interpersonal Theory of Psychiatry. New York: Norton, 1953.
Worden, J.W. Grief Counseling and Grief Therapy: A Handbook for Mental
Health Practitioners, 2nd ed. New York: Springer, 1991.
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3
Analyses of Crisis Expanding the Framework
By speaking of our misfortunes we often relieve them.
Pierre Corneille
No one discipline or school of thought can claim crisis theory as its own, for the
theory has been derived from a variety of sources. The result, therefore, is an
eclectic framework that is deceptively simple but is drawn in part from general
systems theory, psychoanalytic theory, adaptational theory, and interpersonal
theory.
Systems Theory and Crisis
The terrain of human behavior is so vast that a single perspective can reveal
only certain features. Although somewhat reductionistic, systems theory has
the virtue of showing relationships and interdependence among people, and
between people and events. A systems approach to human behavior is
comprehensive enough to organize disparate concepts into a coherent
framework, even though the multiple structural and functional aspects of
human relationships may not be fully addressed. In a discussion of family
systems, Carter and McGoldrick (1980) noted the importance of simultaneously
adopting a horizontal and a vertical perspective. A horizontal view
encompasses the everyday stress and tensions of family life, whereas a vertical
view encompasses intergenerational patterns of relating and functioning.
Among the organizational strengths of systems theory are the following
concepts:
Systems theory differentiates functional and dysfunctional behaviors. This
distinction facilitates identification of individual and family interactions for
which corrective feedback may be necessary.
Page 42
Page 43
Early psychoanalytic work was of relatively brief duration, but gradually the
process became lengthier. The technique of free association demands passivity
and neutrality from the therapist, which, along with transference, prolongs the
therapeutic process, for there is virtually no limit to the distortions of early life
that utilize images of mother, father, siblings, and others projected on the
analyst so as to promote insight. Insight refers to the ability to establish
connections between behaviors and their underlying motivation. The
acquisition of insight during psychoanalysis is a cognitive and emotional
process achieved through free association, transference phenomena, and the
therapeutic reenactment of earlier experiences as the client's resistance to
change is moderated and maladaptive behaviors relinquished.
During the 1920s some attempts were made to shorten the time needed for
psychoanalysis. Ferenczi (1926) modified traditional analysis by introducing
calculated interventions that encouraged clients to disclose their fantasies and
provoked frustration in the client so as to heighten willingness to change. Rank
(1929) devoted considerable attention to the traumatic experience of birth and
advocated nine gestational months of psychotherapy to counter the adverse
emotional experience of leaving the womb. Despite the advocacy of Ferenczi
and Rank, Freud was opposed to shortening the length of psychoanalysis. His
stance impeded the movement toward briefer therapeutic encounters and
strengthened adherence to psychoanalytic treatment, which sometimes
seemed endlessly prolonged.
Almost two decades later, Alexander and French (1946) proposed other drastic
revisions of the psychoanalytic protocol followed by most traditionalists. What
the revisionists sought was the substitution of active, brief psychotherapy for
the tedious methods of classic psychoanalysis then in vogue. Their suggestions
were ignored for a time even in the face of growing demand for mental health
services. It was not until the work of Lindemann and Caplan became known
that brief psychotherapy was considered to have intrinsic value.
Although Freud questioned the merits of brief therapeutic encounters, he
formulated two hypotheses that are of inestimable value in understanding crisis
theory. One was the principle of psychic determinism, which challenged the
premise that human behavior is accidental or random. Psychic determinism is a
theory of causality that assumes that all behavior is purposeful and meaningful,
and that the causes of behavior originate in the previous experiences of
Page 44
imperils survival.
It is possible to identify prevailing behavioral patterns in individuals, although
most persons have a repertoire of available responses from which to choose.
Moreover, several dysfunctional behaviors may be expressed either
simultaneously or sequentially. For example, an employee experiencing
frustration on the job may displace anger to family members or friends who are
unlikely to retaliate. In addition, hostility may be
Page 45
projected to co-workers in the mistaken belief that they are antagonists. These
psychological defenses of displacement and projection may be expressed
through belligerence, withdrawal, depression, or defeatism. Essential to
effective adaptation is the ability to learn from, but not be controlled by, past
experience; to appraise the demands of the moment; and to respond
selectively to the current situation. Although constrained to some extent by
individual potential and social resources, adaptiveness is considered a behavior
that can be acquired or improved through appropriate intervention.
Interpersonal Theory and Crisis
Interpersonal relationships from infancy through adulthood were a major
concern of Sullivan (1953), who saw human personality as the product of a
network of social arrangements. The self-system of every individual is based on
the reflected appraisals of others, and psychological disturbances are
considered to be reactions to difficult life situations. In his work, Sullivan used
direct communication between client and therapist, avoiding free association.
One of the most profound tenets of this inter-personal framework is the
theorem of reciprocal emotion, which states that persons who think well of
themselves tend to think well of other people, while persons deficient in selfesteem tend to perceive other people as equally unworthy. Individuals who
lack a sense of self-worth project their feelings of worthlessness to others. The
result is that they believe themselves to be surrounded by enemies inhabiting a
harsh and treacherous world. Such individuals are often victims of self-fulfilling
prophecy. Anticipating injury, they search for it and are seldom disappointed.
Expecting not to be successful, they have a propensity for meeting failure and
disappointment.
When children are highly valued and treated tenderly, they experience the self
as good. When children are subjected to harshness and disapproval, they think
of themselves as bad, with consequent feelings of worthlessness, anger, and
anxiety. These children develop malevolent attitudes toward a world that
always seems threatening. Their basic perceptions have been determined by
negative interpersonal experiences that propel them into similar experiences in
later life. Sullivan attributed anxiety to the ever-present need for approval from
significant persons. If approval is forthcoming, a child experiences a
pleasurable state of euphoria, which Sullivan termed the absence of anxiety. It
is the child's attempt to obtain approval and preserve euphoria, combined with
Page 46
ter both clinician and client are engaged in an unfolding relationship in which
the client's interactional patterns are identified. Verbal and nonverbal
components of the encounter are used to point out behaviors and experiences
that have brought the client to the present impasse. The interpersonal
framework uses the therapeutic session as an intricate transaction that is
structured by the clinician. In utilizing an interpersonal approach to crisis work,
a clinician may adopt the following guidelines for structuring the sessions:
Ascertain the presenting problem brought to the session. For example, the
presenting complaint of a troubled wife may be her husband's infidelity, but
the actual problem is the couple's inability to tolerate their middle years
without the presence of children in the home. In this event the presenting
problem will be the initial focus of attention. If the couple is willing, the
underlying problem may be addressed later.
Estimate the relative amount of pleasure and pain currently experienced by the
client or clients, as well as the sources of gratification and frustration
experienced in daily life.
Investigate attributes and abilities that clients either value or devalue in
themselves. For instance, a college honors student might discount academic
achievement and consider scholarship effete compared with being a member of
a varsity team.
Observe the defensive behaviors used by clients to maintain feelings of
security. Defensive behaviors might include selective inattention, focal
awareness, denial, repression, projection, and rationalization. All issues that
elicit security behaviors are deserving of attention, even if they are not directly
confronted during crisis intervention.
Adhere to the short-term contract required in crisis work but make referrals for
more intensive help if necessary after the crisis has been resolved.
Role of Anxiety in Crisis
A major factor in the disequilibrium of crisis is the presence of anxiety, which
has been described as the most unpleasant human experience, with the
possible exception of loneliness (Sullivan, 1953). Signal anxiety was the term
Freud used to denote a response to anticipated threat that signaled ego forces
to oppose the threat. Simply stated, signal anxiety represents internal
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periodically throughout life until final separation occurs in the form of death. A
connection between anxiety and hostility was identified by Horney (1939), who
believed that anxiety originated in fears of interpersonal rejection. Erikson
(1963) distinguished between fears of recognizable peril and anxiety, which is
likely to be disproportionate to the actual threat.
Despite semantic differences, there is agreement that anxiety is a distressing
state characterized by diffuse feelings of apprehension, uncertainty, and
imminent disaster. The causes of anxiety are variously ascribed to separation,
isolation, alienation, disapproval, fear of punishment, withdrawal of love, and
disruption of meaningful relatedness. Any circumstance that constitutes a
threat to inner security, whether psychological or biological, is likely to
generate an uncomfortable amount of anxiety.
Anxiety appears in varying amounts and with varying frequency. For some
individuals, anxiety is a characterological trait rather than an occasional state
or condition. The turmoil of the anxiety-prone person has been aptly described
by Freud, who wrote that for some persons there is "a quantum of anxiety in a
free floating condition which in any state of expectation controls the selection
of ideas and is ever ready to attach itself to any suitable ideational content"
(Thompson, 1957). In other words, diffuse anxiety tends to find any means to
perpetuate itself in susceptible individuals. Chronic anxiety is of long duration
and relatively low intensity. Acute anxiety is of shorter duration and relatively
high intensity. For anxiety-prone persons, periods of acute anxiety are all too
common, and chronic anxiety is a respite between frequent periods of greater
discomfort. These individuals have fluctuating levels of discomfort with acute
periods of severe anxiety superimposed on chronicity.
Anxiety has the power to generate energy, but when levels are excessive the
energy becomes undirected and disintegrative. (See Table 3-1.) Mild anxiety,
however, releases energy that can be directed toward problem solving.
Moderate anxiety causes decreased efficiency, whereas more severe anxiety
leads to frustration and feelings of entrapment. When anxiety is severe enough
to be called panic, all available energy is directed toward escape. If escape is
impossible, there is temporary disintegration of personality that may evoke
destructive behavior toward oneself or others. Disequilibrium that accompanies
crisis is a reflection of anxiety that hovers between severe and panic levels.
For all persons in crisis, anxiety is a common denominator that can become the
Page 48
TABLE 3-1 Anxiety: Levels, Characteristics, and Interventions
Mild
Moderate
Severe
Euphoria
Panic
Anxiety
Anxiety
Anxiety
Selective
Perceptual
Absence of
Reduced
perception distortions.
Alertness
anxiety.
perception,
and
Inability to
and
Sense of
concentration, attention.
communicate.
vigilance.
well-being.
communication.Subjective Inability to
distress.
function.
Interventions
Encourage
Reconcile demands of
motor
the situation and
activity.
Provide
expectations of the
Facilitate
Maintain
structure and
individual. Trace
cognitive and
connections
direction until
connections between
affective
to reality.
anxiety
causes and
expression
decreases.
manifestations of
(walking,
anxiety.
talking,
crying).
Source: Adapted from Sullivan (1953) and Peplau (1952).
destructive, force. Delineating the outlines of the actual crisis and exploring
problem-solving efforts
Page 49
of the immediate past are interventions that help clients reduce anxiety to
manageable levels. The timing of interventions is important, for there are limits
to the ability of clients in crisis to move rapidly toward insight or to understand
dynamic interpretations of the causes for their difficulties.
Physiological outlets are available for expressing anxiety, usually by means of a
hyperactive sympathetic nervous system. Sweating, tachycardia, pupillary
changes, hyperventilation, and gastrointestinal symptoms are some of the ways
in which anxiety finds physiological expression. Anxiety is akin to fear, but
when fear becomes anxiety there is a shift from recognition of a known threat
to an inner apprehension that may overwhelm the individual. One cannot run
away from anxiety just as one cannot run away from guilt, because both are
internal experiences that operate independently of external reality.
The clinical implications of anxiety have been studied by a number of nursetheorists, and the concept of anxiety has been accepted as a valid nursing
diagnosis. The most extensive investigation of anxiety by a nurse-theorist was
done by Hildegarde Peplau. In work that has become a prototype of nursing
theory, Peplau developed an operational definition of the term anxiety,
discussed causes and effects of anxiety, and outlined four progressive levels of
anxiety, along with appropriate interventions at each level (Peplau, 1952).
Preferred behavioral patterns often constitute a means of handling anxiety.
Therefore, behavior can be both a manifestation of anxiety and a defense
against the discomfort it brings. During the disequilibrium of crisis, individuals
are frustrated as well as anxious. The cause of frustration is the inability to
resolve the crisis successfully, and the effect of frustration is a feeling of
deprivation or entrapment. Responses to frustration are individualistic. Some
frustrated persons will experiment with one solution after another, searching
for new ways of coping as soon as ineffective methods are discarded. Other
individuals procrastinate, becoming irresolute and indecisive. Not infrequently,
frustrated persons grow angry, projecting their feelings of inadequacy to the
crisis worker, who is then labeled inept, or displacing their feelings on any
other available target. Other frustrated persons measure their own worth
against events over which they have little control and attribute their
predicament to their own deficiencies. Self-deprecation is counterproductive,
since it gives rise to feelings of helplessness and hopelessness. Behaviors
apparent during the disequilibrium of crisis are often variations of the following
patterns:
1. Fight-flight behavior: Blaming, avoidance.
2. Conflicted behavior: Ambivalence, irresolution.
3. Helpless behavior: Dependency, passivity.
4. Hopeless behavior: Regression, surrender.
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Fight-flight behavior may take the form of blaming others (fight) or of evading
responsibility (flight). Conflicted behavior may be expressed through
ambivalence or through tendencies to fulfill obligations partially but not
entirely. Helplessness takes the form of overt dependency and reluctance to
participate in problem solving. Hopelessness produces surrender behavior and
regression expressed through apathy and withdrawal. Identification of
prevailing behavior patterns is an essential part of assessment during meetings
between clients and crisis workers.
Types of Crisis Work
Treatment methods in crisis work are similar to other forms of treatment that
attempt to alter behavior within a short time period. Not all crisis intervention
comes under the rubric of psychotherapy, but there are broad distinctions that
can be applied to both. In general, brief psychotherapy may be divided into
two classifications based on objectives and the characteristics of clients for
whom they are suitable. Sifneos (1967, 1980) described two types of brief
psychotherapy: (1) anxiety provoking or dynamic, and (2) anxiety suppressive
or supportive. The criteria for patient selection, the intervention strategies, and
the outcome objectives of the two types of treatment are quite divergent.
Short-term Anxiety-provoking Treatment
Essential to short-term anxiety-provoking treatment is the belief that a certain
level of anxiety is needed to motivate clients to examine the underlying
dynamics or causes that produce maladaptive behaviors. Although the clinician
monitors proceedings so that overwhelming anxiety is avoided, confrontation
and interpretation are employed to explore the client's customary behavioral
responses. It is not necessary or even desirable that interventions be unduly
harsh, but it is important that they be more than merely supportive. Improved
functioning can sometimes be obtained through exploratory interventions that
promote introspection, identify similarities between the current situation and
earlier situations, and make connections between present and previous
behavioral responses.
Anxiety-provoking brief treatment can be further divided into therapy that lasts
from two months up to one year, and crisis work that lasts up to two months.
In anxiety-provoking crisis work, the client is in a state of temporary
disorganization because of a developmental or situational impasse.
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the crisis will have abated. Treatment may then be terminated or a referral
made for additional help that is not crisis oriented. All forms of anxietyprovoking treatment, whether limited to six weeks or lasting a year, include
within their purview some degree of behavioral or psychological change and
also offer anticipatory guidance for the future. For purposes of clarification,
traditional psychoanalysis is a form of anxiety-provoking therapy that may last
several years.
Certain requirements must be met before short-term anxiety-provoking
treatment is attempted. First, the clinician must have comprehensive
knowledge of psychodynamics. Although this type of therapy is offered by
psychiatrists, psychologists, social workers, and psychiatric nurses, it should be
performed only by experienced individuals who possess a graduate degree in
their discipline and have access to qualified supervision or consultation.
Selection of candidates for anxiety-provoking brief therapy should be done very
carefully. In this form of treatment, clients must have sufficient psychological
strength to withstand increased levels of anxiety, since anxiety is used to
induce clients to alter their behavioral responses. According to Sifneos (1967,
1980), clients suitable for anxiety-provoking treatment should meet the
following criteria:
Clients must have at least average intelligence.
Clients must have at least one meaningful relationship.
Clients must have an identifiable problem.
Clients must be interested in solving the problem.
Clients must be willing to set realistic goals.
Clients must be able to express emotion or affect.
Anxiety-provoking Crisis Intervention
Sometimes called exploratory crisis work, anxiety-provoking crisis intervention
attempts to maintain or improve the client's coping skills by means of
techniques that emphasize the following issues:
Rapport between client and clinician.
Review of sequence leading to crisis.
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critical issues may begin. Supportive crisis work may be used to help individuals
surmount situational or developmental tasks that have caused or may cause
severe decompensation. As in all crisis work, it may be advisable after
expiration of the acute period to refer clients for additional help. Occasionally
an individual who has received supportive
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Table 3-2 Anxiety-provoking and Anxiety-suppressing Treatment
Approaches
Type of
Duration
Goals
Client Characteristics
Treatment
Problem
Psychological stability
solving
Exploration Social resources
2
AnxietyPsychological
months
provoking
growth
to 1
Average intelligence or
brief therapy
Behavioral
year
more emotional
change
expressiveness
Anticipatory
guidance
Problem
Psychological stability
solving
Situational
Social resources
change
Anxiety6 to 8
provoking
Exploration
weeks
crisis therapy
Behavioral Average intelligence or
change
more crisis disequilibrium
Anticipatory emotional expressiveness
guidance
Support
Emotional vulnerability
reassurance
Symptom
Possible deterioration
relief
2
Anxietymonths Problem
suppressive
to 1
solving
brief therapy
year
Behavioral
change
Anticipatory
guidance
Support
Emotional vulnerability
reassurance
Symptom
Crisis disequilibrium
relief
Anxiety6 to 8 Situational
suppressive
Imminent deterioration
weeks change
crisis work
Problem
solving
Anticipatory
guidance
discharged and referred to a crisis team working in a mental health center. The
group was an interdisciplinary unit that functioned as a treatment and referral team
for persons without previous psychiatric history.
Jim's anxiety attack was interpreted as a response to his ambivalence about being a
post office employee. Questioning Jim about his high school years led to a rhapsodic
description of his interest in camping and the outdoors. Jim expressed strong dislike
for the confines of cities and said that his ambition was to work as a forest ranger.
However, he had never considered this ambition to be realistic, nor had he ever
been led to believe that one's job should be rewarding, except in monetary terms.
One worked in order to live, and it was a foregone conclusion that
Page 55
one's life work would be routine and monotonous. Jim had watched his father on his
daily rounds, carrying a heavy mail bag and trudging endlessly over the same city
streets. The prospect of the same job intimidated Jim, but he hesitated to oppose
his father's wish that he take advantage of the security offered by a post office job.
In discussing treatment for Jim, two alternative approaches were considered by the
crisis team.
Alternative One: Anxiety-suppressive Crisis Work. The crisis worker encouraged
Jim's fondness for the outdoors and his timid wish for a career that would allow him
to express this interest. A likable young man of average intelligence, Jim was
encouraged to investigate fields of employment that were more to his liking. The
oldest of four children, Jim felt a sense of urgency about finding a job quickly. He
was somewhat intimidated by his forceful father. Therefore, the crisis worker invited
Jim's parents to two of the eight sessions that had been arranged.
During the meetings that Jim's parents attended, the crisis worker became an
intermediary, supporting Jim's ambitions and reassuring Jim's father that viable
economic opportunities existed outside the postal service. With the help of the crisis
worker, parents and son were able to communicate more easily. A referral to a
respected vocational counseling program was made for Jim. During the last session,
when Jim met alone with the crisis worker, he reported that he was now
investigating job opportunities in national parks. His father no longer insisted that
Jim take a job at the post office and had remarked jokingly that ''forest rangers and
mail carriers all worked for the same boss-Uncle Sam."
Alternative Two: Anxiety-provoking Crisis Work. In this approach, Jim's anxiety
attack was interpreted as maladaptive behavior used because Jim was unable to
express his feelings appropriately. Considerable attention was given to interactions
between Jim and his father. Although it was true that Jim's father was opinionated,
it seemed to the crisis worker that the problem lay less in the father's forcefulness
than in Jim's timidity. The crisis worker listened attentively as Jim described his love
of the outdoors and tentatively suggested that perhaps Jim was less comfortable
with other people than he would like to be. Jim admitted that he felt inept socially
except when he was camping or hiking outdoors. There he always felt confident and
in his element.
The crisis worker and Jim established a contract for eight sessions, at the end of
which renegotiation would occur. The parents were invited to one session, and with
Jim's collaboration the following goals were formulated:
1. Explore the possibility that Jim's love of outdoor life might be an avoidance tactic.
2. Examine the feelings and experiences that caused Jim to feel socially inadequate.
3. Support Jim's right to choose his own vocation and provide guidance.
Page 56
4. Encourage Jim to express his career preferences to his parents, especially his
father.
5. Refer Jim to a vocational counselor to help clarify career choices.
By the end of the crisis contract, more than Jim's career options had been explored.
Jim was persuaded that he should become more assertive and autonomous. Clear
communication channels were opened between Jim and his parents, but major
responsibility for keeping the channels open was given to Jim. Jim's father was not
labeled an overbearing tyrant, but a worried parent who did not understand Jim's
ambitions but might be willing to listen. The choice of a vocation was described as
Jim's inalienable right, but the search for opportunities was also his.
Because this approach was anxiety provoking and specific to Jim, a decision was
made that Jim required further help after expiration of the crisis contract. When Jim
terminated with the crisis worker, he was already meeting with a vocational
counselor, and aptitude tests had been arranged. A referral was made to a social
learning group composed of other young people near Jim's age. By the end of eight
weeks, the crisis situation had been resolved and Jim faced the immediate future
with new allies and new coping skills. He felt anxious about joining the social
learning group but believed the effects would be beneficial. At the time of
termination, the crisis worker assured Jim of the worker's continued availability but
expressed confidence and respect for Jim's newfound insight.
Critical Guidelines
Most mental health facilities are staffed with therapists and counselors who use
various orientations in their work. Ideally, every client would be assigned to a
particular form of treatment based on the presenting problem and the client's
needs. Oliver et al. (1988) found that there was relatively little research on the
connection between clients' characteristics and their assignment to a particular form
of therapy. A number of studies have shown that certain demographic
characteristics such as race, educational level, and socioeconomic status influence
the kind of treatment offered to individuals and families.
In choosing anxiety-provoking approaches for a person in crisis, therapists must use
careful assessment and unstructured interviewing to determine whether an
individual is capable of tolerating this form of intervention. In the early phases of
acute crisis, no client should be subjected to anxiety that is deliberately escalated
by the therapeutic approach. Only after anxiety has subsided and rapport has been
established can accurate assessments be made of the client's tolerance for
exploratory interventions. The safest course in crisis counseling, as in most forms of
therapy, is to begin with anxiety-suppressive interventions and
Page 57
to adopt an alternative approach only if clients have sufficient ego strength, are
motivated, and are likely to benefit.
Anxiety-provoking intervention is not for the inexperienced therapist even if the
client is an appropriate candidate. In such instances referral to another therapist is
advisable. Some clinicians who possess skills and expertise necessary for anxietyprovoking therapy regard it as a form of primary or tertiary prevention. Primary
prevention has the objective of anticipating future hazards and preparing the client
to deal with them. Tertiary prevention has the objective of minimizing disability by
reinforcing new ways of coping.
Piha (1988) observed that persons with a previous psychiatric history were less able
to manage demanding situations than persons with no psychiatric history. Since
anxiety-provoking therapy makes special demands on clients, the approach should
be limited to persons with considerable psychological strength. The choice of
anxiety-provoking over anxiety-suppressing therapy depends on the stage of the
crisis. Even more important is the assessment of the client's overall resources,
interpersonal, environmental, and psychodynamic. Table 3-3 shows the cognitive,
emotional, and behavioral reactions to anxiety.
Most people modify their behavior according to their circumstances. Even those who
function well, however, have a preferred style of reacting and interacting. This
preferred style is determined by social learning, temperament, personality traits,
cultural expectations, and other influences. In general, rising anxiety tends to
reinforce an individual's preferred interactional style. Table 3-4 describes the
strengths and weaknesses characteristic of interactional styles.
Summary
Crisis theory draws from a number of theoretical sources. General systems
theory, psychoanalytic theory, adaptational theory, and interpersonal theory
have contributed to the crisis treatment framework. In the disequilibrium that
accompanies crisis, anxiety is always present and the discomfort of anxiety
provides an impetus for change. Some people are more able than others to
tolerate anxiety, thus the ability to tolerate high levels of anxiety is a major
factor in selecting an anxiety-provoking or an anxiety-suppressing treatment
approach for a person in crisis.
During the most acute phase of disequilibrium, few persons can tolerate
additional anxiety, but as problem solving begins some individuals are capable
of responding well to anxiety-provoking interventions that are exploratory in
nature. Selection of an anxiety-provoking treatment plan should be determined
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TABLE 3-3 Cognitive, Emotional, and Behavioral Reactions to
Anxiety
Levels of
Corrective
Cognitive/BehavioralCognitive/Emotional
Anxiety
Interventions
Mild
Recognition of
Alertness
Noises seem louder.
anxiety
anxiety as a
Vigilance
Restlessness
warning sign
that
something is
not going as
expected. This
can be done
by:
1. Observing
what goes
on.
2. Describing
what goes
on.
3. Analyzing
what was
expected.
4. Analyzing
Irritability
how the
expectations
and what
went on
differed.
+
5.
Formulating
what can be
done about
the situation
in terms of
changing the
situation or
changing the
expectations.
6. Validating
with others.
Recognition +Increased
Reduced power to
Moderate
perceive and
anxiety
communicate.
Concentration on that in
+tension
problem.
moderate and
Someone talking, severe anxiety
may not be heard. the focus is
Part of the room
reduced and
may not be noticed. connections
may not be
seen between
details and
that anxiety
provides
energy which
can be
reduced to
mild anxiety
and then used
to find out
what went
wrong.
Muscle
tension,
pounding
heart,
perspiration,
stomach
discomfort.
Page 59
Page 60
TABLE 3-4 Interactional Styles
Interactional Style
Strengths
Weaknesses
Willing to trust Expect a great deal from
others.
others.
Sacrifice independence
Aware of their
for fear of losing people
own needs.
they need.
Passive/dependent
Able to rely on
May substitute substance
others.
dependence (alcohol) for
Seek and accept
personal dependence.
help.
Willing to trust Resent their need for
others.
others.
Aware of their Express anger indirectly
own needs.
toward those they need.
Passive/aggressive
May substitute substance
Able to rely on
dependence (alcohol,
others to some
drugs) for personal
extent.
dependence.
Extreme self-sacrifice
Sacrifice self for
leads to anger and
others.
bitterness.
Willing to serve
others.
Masochistic
Willing to defer May hurt others if they
own needs.
feel unappreciated
Prefer hurting (sadomasochism).
the self to
hurting others.
Strong need for Unable/unwilling to
order.
accept help.
Need to be in Trust self more than
control.
others.
Obsessive/compulsive Careful with
Uncomfortable with
details.
strong emotion.
Comfortable
Prefer personal distance
with routines
to closeness with others.
and schedules.
Comfortable
Unreliable in completing
with strong
difficult tasks.
emotions.
Hysterical
More interested
Reluctant to share the
in the "big
picture" than in limelight.
details.
Enjoy changes
in routines and
Vacillate between
schedules.
managing own life and
Enjoy being the
wanting to be cared for.
center of
attention.
Often dramatic,
interesting, and
creative.
Usually balance
dependency and
autonomy.
Page 61
References
Alexander, F., and T. French. Psychoanalytic Theory. New York: Ronald, 1946.
Carter, E.A., and M. McGoldrick. The Family Life Cycle. New York: Gardner,
1980.
Erikson, E. Childhood and Society. New York: Norton, 1963.
Ferenczi, S. Further Contributions to the Theory and Technique of
Psychoanalysis. London: Hogarth, 1926.
Freud, S. Problems of Anxiety. New York: Norton, 1938.
Horney, K. New Ways in Psychoanalysis. New York: Norton, 1939.
Oliver, J.M., H.R. Searight, and S. Lightfoot. "Client Characteristics as
Determinants of Intervention Modality and Therapy Progress." American
Journal of Orthopsychiatry 58(1988): 543-551.
Peplau, H. Interpersonal Relations in Nursing. New York: Putnam, 1952.
Piha, J. "Psychosocial Coping in Young Adulthood of Male Child Psychiatric
Outpatients: Implications of Early Treatment." American Journal of
Orthopsychiatry 58(1988): 524-531.
Rank, O. Will Therapy and Truth and Reality. New York: Knopf, 1945.
Sifneos, P.S. "Two Different Kinds of Psychotherapy of Short Duration."
American Journal of Psychiatry 123(1967): 1069-1074.
Sifneos, P.S. "Brief Psychotherapy and Crisis Intervention." In Comprehensive
Textbook of Psychiatry, 3d ed., vol. 2, edited by H.I. Kaplan, A.M. Freedman,
and B.J. Sadock. Baltimore: Williams & Wilkins, 1980.
Sullivan, H.S. The Interpersonal Theory of Psychiatry. New York: Norton, 1953.
Thompson, C. Psychoanalysis: Evolution and Development: A Review of Theory
and Therapy. New York: Grove, 1957.
Weiner, M.F. "Theories of Personality and Psychopathology: Other
Psychodynamic Schools." In Comprehensive Textbook of Psychiatry, 4th ed.,
edited by H.I. Kaplan and B.J. Sadock. Baltimore: Williams & Wilkins, 1985.
Page 63
4
Categories of Crisis:
Choosing an Approach
Where there is much desire to learn, there of necessity will be much arguing, much
writing, many opinions; for opinion in good men is but knowledge in the making.
John Milton
Page 64
necessary, however, to assess the crisis in the context of the individual's life
situation and psychosocial experience. Among clinicians and theoreticians,
there is widespread agreement that crisis is an individualized response that
results from the meaning of the event rather than from the obstacle itself. Even
though crisis work deals primarily with the here and now, adequate
assessment, planning, and implementation must consider not only the
problem, but also the psychodynamic experience of the client.
As crisis theory became formalized, attempts were made to differentiate types
of crisis. Using one set of criteria, two major types of crisis have been
identified: (1) developmental or universal crises, and (2) situational or episodic
crises. Developmental crises are maturational events that are expected but
which produce changes that necessitate new coping methods. Situational
crises result from unexpected episodes that also produce change and
necessitate new coping methods. In a somewhat similar triadic classification,
Schneidman (1973) described crises as intertemporal, or characteristic of a
transitional life stage; intratemporal, or characteristic of an attained life stage;
and extratemporal, or unrelated to any particular life stage.
Developmental Crises
The foremost explicator of developmental crises was Erikson (1963), who
identified essential developmental tasks to be accomplished during the life
cycle. It was his contention that there are eight life stages, each with its own
critical task. Within each life stage there is a period of ascendance during
which the critical task for that stage must be surmounted. Ascendancy stems
from the combined urgency of social, psychological, and physiological forces
acting on the individual. Failure to accomplish early critical tasks impairs ability
to deal adequately with later tasks and contributes to psychological
vulnerability.
Momentous occasions, such as graduating from college, getting a job,
marrying, or becoming a parent, have been called marker events (Sheehy,
1976). Although marker events are crucial, they do not of themselves comprise
developmental stages. Developmental stages result from subtle feelings and
pressures arising within individuals; even when marker events are absent from
the life of an individual, the impetus for developmental advancement remains.
Thus, changes resulting from market events may lead to disequilibrium, but so
may the absence of marker events. When marker events do occur, the
Page 65
Page 66
marriage, parenthood, aging, and death. Many similarities exist between the
terms critical tasks and marker events; however, critical tasks represent
abstract, internal experiences, whereas marker events tend to be concrete and
external. Role expectations and ceremonial rites of passage, such as weddings,
graduations, and anniversary celebrations are among the practices society uses
to monitor individual development. Erickson sometimes applied the word crisis
to the stages of his developmental model, but critical task is more accurate.
When critical tasks are successfully accomplished, the needs of the individual
and society are met. The result is an absence of crisis. Failure or inadequacy
around critical tasks increases the probability of crisis whenever later tasks are
ascendant.
Even though most developmental tasks can be anticipated and prepared for in
advance, many are never fully resolved. Resolution of critical tasks is rarely
completed but is a continuous lifelong process. All changes impose new
demands on people; when individuals cannot find ways to cope with
developmental or situational change, disequilibrium and crisis may follow. In
dealing with expected change, anticipatory guidance is an intervention
strategy that may be used to prepare for impending events. This strategy was
described by Caplan (1964) as a form of ''emotional inoculation," which is
effective in building psychological defenses against the hazards of prospective
change. Since critical tasks are stage specific, it is possible to predict change
and to identify vulnerable populations. One example of a target population is
very young mothers who must deal with parenthood before their adolescent
task of identity has been completed. In most cases, adaptive resolution of
development tasks depends on the previous experience of the individual,
motivation and coping skills brought to the task, and access to appropriate
assistance support.
POPULAR MYTHS ABOUT CRISIS INTERVENTION
Myth One. Crisis intervention is appropriate only for
psychiatric emergencies.
Myth Two. Crisis intervention is limited to a single
therapeutic session.
Myth Three. Crisis therapy is practiced only by
paraprofessionals.
Page 67
Situational Crises
Most situational crises are considered extratemporal in that they occur
randomly and are independent of any developmental stage. Because they are
seldom anticipated, situational crises take people by surprise. As with
developmental crises, adequacy of coping skills acquired previously influences
adaptive crisis resolution. Any change in one's life or circumstances, whether
positive or negative, may precipitate crisis. In a study that established mean
scores for certain life changes, the death of a spouse constituted the greatest
stress, followed by divorce and marital separation. Personal injury or illness was
found to be a significant cause of stress, as was any change in financial status.
Lower on the scale but still consequential were such disparate events as job
losses and outstanding personal achievements. Clusters of change within a
short time span were found to increase the likelihood of crisis arising within a
year, usually in the form of physical illness (Holmes & Masuda, 1973; Holmes &
Rahe, 1967).
Compound Crises
The term "compound crisis" describes the experience of some clients currently
undergoing a traumatic event that is intensified by memories of previous losses
that had receded from consciousness until reactivated by present
circumstances (Horsley, 1988). Many care providers not practicing in mental
health settings will encounter the phenomenon of compound crisis in clients
facing illness or injury to themselves, or a family member, whose inability to
cope is related to unresolved events of the past. The memory of past crises
intrudes on the present; the difficulties of the present situation are
compounded by old griefs, so that the energy needed to deal with the new
problems is depleted and recuperative powers are doubly threatened. Clients
dealing with a compound crisis often are extremely sensitive to incidents that
seem trivial to staff members. They may become withdrawn, very demanding,
or apparently uncooperative. With such clients the care provider should call
upon a psychiatric specialist who will help upset staff members deal with their
reactions to the difficult client and, in some instances, explore with the client
the meaning of the maladaptive behaviors.
Clients displaying extreme reactions to the current situation may or may not be
suffering compound crisis. Exploration of past events in the life of the client
helps determine whether unresolved grief is present. Sometimes there is no
history of previous trauma or loss. At other times there have been previous
crises, but the client is able to discuss them with appropriate emotionality,
showing neither uncontrolled nor deficient reactions. When clients are dealing
primarily with the current situation, they may be angry and anxious, but they
are able to think about the
Page 68
future. When clients are dealing with compound crisis they are more apt to
respond to the present situation with depression, apathy, or surrender, rather
than anxiety. The result of compound crisis is lack of energy or desire to meet
the challenge of the current situation.
The following is a therapeutic model for intervention with an individual
experiencing a compound crisis.
Examine the current situation to determine what factors in the present crisis
are evoking past experiences of trauma or loss.
Search for similarities and differences between present and past conditions.
Focus on past and present stressors in ways that reinforce the client's
strengths; express confidence in the client's coping skills.
Help the client identify his or her preferred methods of coping now and in the
past.
Use cognitive interpretations to help the client understand the influence of past
experiences on current reactions.
Within the limited scope of the crisis model, encourage the client to move from
the past to the present.
Permit the client to express residual grief and sorrow for past events, thereby
reducing the intensity of memories of previous crises.
Refer the client for follow-up counseling if previous and current distress cannot
be dealt with adequately in the time allowed.
Interpret the client's behavior as an indication of compound crisis rather than
as a weakness or a desire to be troublesome.
Clinical Example: Illness as a Compound Crisis
Mrs. Franklin was hospitalized on a surgical unit for a radical mastectomy. She was
forty-five years old, the wife of a prominent business man, and the mother of three
teenage children. She had handled her ordeal extremely well in the opinion of her
surgeon and the nursing staff. Her demands on staff were minimal and she was
regarded as an ideal patient. The Franklin family was a close one and the children
visited daily after school. Mr. Franklin was unable to visit every day because of
business pressures, but he came in several times a week. His wife's room was full of
gifts and flowers sent by the family and friends. Only the immediate family was
permitted to visit, at Mrs. Franklin's request, and she had asked not to have her
phone connected. Although her primary nurse was concerned about Mrs. Franklin's
withdrawal, she was reassured by the fact that her client seemed bright and
animated whenever her husband and children visited.
As the days passed the nurse became more and more concerned. When it was
suggested that Mrs. Franklin walk a little to
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regain her strength, she complied but walked only within her own room. She kept
her door closed, spoke politely to staff, but initiated no conversation except with her
own family. The primary nurse was experienced enough to recognize signs of
deepening depression and was not surprised to find her cooperative client crying
bitterly one morning. Mrs. Franklin said she was merely tired after a sleepless night,
but when her nurse suggested that Mrs. Franklin might like to talk with a mental
health nurse, the client agreed.
When the nurse specialist visited, she expected Mrs. Franklin to talk about her
changed body image and misgivings about her sexuality. Introducing these topics
caused Mrs. Franklin to smile ruefully and dismiss the subject with a wave of her
wellmanicured hand. It was only when the nurse specialist introduced the topic of
the Franklin children that the client's defenses began to crumble. The nurse realized
that this was an area that needed to be explored and asked about the children's
reaction to their mother's surgery. The question caused the client to talk about her
fears of dying and abandoning her children at a time when they still needed her.
She said that she had grown up in a motherless home and it was the last thing she
wanted to happen to her own children. She described her feelings as a child of ten
when her mother had died. She remembered being the object of much solicitude
that had quickly diminished as people were caught up in their own affairs. Her
grandmother, a stern and straitlaced woman, had come to live with Mrs. Franklin,
who was an only child. She remembered being told that she mustn't cry for her
mother because her father would be unhappy and he was doing his best to be both
mother and father. Mrs. Franklin also had memories of being dressed in a funny, oldfashioned way as a child, of never having a birthday party, and of being more
restricted than other youngsters her age.
Critical Guidelines
As a result of her own childhood, Mrs. Franklin had resolved to make her husband
and family as comfortable and happy as possible. She had evidently succeeded, for
the devotion shown by her husband and children was remarkable. From her remarks
it was evident that Mrs. Franklin was reliving her own emotionally barren childhood
and foreseeing the same fate for her children. The nurse specialist recognized that
Mrs. Franklin was suffering a compound crisis related to her own surgery and to her
memories of a mother who had died.
Listening to Mrs. Franklin talk about her mother's death, the nurse specialist realized
that the client's emotional reactions stemmed from her painful association of her
current situation with the past. While accepting the reality of the client's feelings
about her mother's death, the nurse specialist pointed out the differences in the two
situations. Mrs. Franklin's mother had succumbed to pneumonia at a time when
antibiotic drugs were unknown. The client's condition was discovered by
mammography at a very early stage and the prognosis was excellent. The
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only real similarity in the two situations was that two mothers, a generation apart,
had become ill. The energy that Mrs. Franklin had devoted to being a wise and
giving mother was still there and could be used to assist her own recovery. In
addition, the energy of the Franklin family was available to be mobilized on her
behalf if she chose to use it. The nurse specialist suggested that shutting herself of
from friends and showing only her heroic side to her family deprived everyone of an
opportunity to be supportive. The nurse specialist met several times with Mrs.
Franklin. In the meetings the client grieved openly for her mother and even began
to smile at her grandmother's quirks and demands. The nurse specialist continued to
emphasize the importance of dealing with the present situation. She pointed out to
the client that she had been strengthened as well as weakened by her childhood
experiences, and that the present situation could be dealt with more easily if it were
not clouded by bitterness about the very different circumstances of the past.
Application Principles
Assessment
It is axiomatic that the basic question in crisis assessment is not "Why has the
client come?" but rather "Why has the client come now?" The distress of clients
in crisis often causes incoherence to the extent that emotional catharsis may
be necessary before any information can be elicited. In beginning the
assessment, the crisis worker should trace a chronology of events by asking
what happened, when various events occurred, who was involved, what
actions were taken before seeking assistance, and what were the effects of
those actions. Sometimes there is no recognizable precipitating event in the
recent past, and questions must then address the more distant past. In the
absence of a clear precipitator, there may be a number of seemingly trivial
events that accumulated and pushed the client into disequilibrium.
As soon as the anxiety of the client has been allayed to the point that meaning
can be comprehended, the nature and limits of crisis work should be explained.
Since accurate and relevant information is essential, it may be necessary to
question other persons in addition to the client. This questioning should be
done with the knowledge and, if feasible, the concurrence of the client. When
the client can understand the proceedings, the short-term nature of crisis work
should be explained. A contract for crisis intervention seldom exceeds eight
weeks, and the client should be told that the major problem will probably be
solved by that time and that crisis treatment will terminate. Possibilities of
other forms of assistance may be suggested and the promise of appropriate
referrals may be extended, but the crisis worker will indicate that additional
help will be
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forthcoming from a different source. There are some workers who prefer not to
mention further assistance, believing that knowledge of this possibility reduces
the client's active participation in crisis resolution. Because the crisis worker
assumes an active role, there is danger that some clients will become
dependent. This danger is negated by discussing the limits of crisis work, by
bringing up the subject of termination as early as possible, and by using
auxiliary resources, such as family, friends, and community agencies.
During assessment, any suicidal or homicidal thoughts of the client must be
appraised. Direct questioning is recommended in assessing suicidal or
homicidal potential. Clients should be asked whether thoughts are entertained
of harming the self of others. If the answer is affirmative, additional questions
should deal with the seriousness of intentions, the comprehensiveness of any
plan, and the availability of means to carry out the plan. There is a fallacious
idea that bringing up the question of suicide or homicide may "put ideas in the
client's head." This notion attributes more power to the clinician than actually
exists. Indeed, if a worker is reluctant to bring up these issues and discuss
them openly, the client will feel inclined to conceal any such intentions. If the
client admits to having a well thought out plan and if means are accessible,
immediate hospitalization should be considered. A history of a previous suicide
attempt is significant, as are such variables as age, sex, and social isolation.
More women than men attempt suicide, but more men accomplish suicide. The
risk of suicide increases with age, although adolescents are high suicide risks
because of their impulsivity. Among women, suicide is accomplished more
frequently by housewives and widows. Men tend to use methods that are
violent, such as hanging or shooting themselves; women tend to ingest pills or
inhale toxic substances, such as carbon monoxide. Suicidal persons who seek
professional help are likely to be ambivalent about ending their own lives and,
therefore, tend to respond to supportive therapeutic measures. Crisis
intervention is effective for suicidal persons who are ordinarily stable but have
been thrown into disequilibrium by sudden stress. Chronically depressed
persons, alcoholics, psychotics, and withdrawn persons without reliable social
networks are not appropriate for crisis work. A suicidal person is frequently an
individual who requires a long-term, meaningful relationship with a caring
person. Such persons may regard short-term intervention and termination after
eight weeks as another abandonment.
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security guards is indicated. Some persons express verbal threats to the safety
of others but have not carried out their threats. As with suicidal persons, the
specificity of the plan and the accessibility of means should be appraised.
Although there are instances in which impulse control is lost without warning,
it is more likely that the crisis has been foreshadowed by past behaviors. If
there is a history of violent behavior in the client's past, or if the present
situation is complicated by addiction, sociopathy, or neurological or psychiatric
disorder, crisis intervention is not appropriate. As a rule, violent and assaultive
persons require emergency treatment followed by long-term therapy. For some
individuals, custodial care is indicated for the protection of the community. In
acute situations, psychiatric evaluation, medication, and external controls in
the form of competent professionals and paraprofessionals are usually sufficient
to calm agitated persons. Disposition and further treatment are determined by
the client's history, the wishes of the family, and the safety of society.
Planning
At times, crisis intervention is generic and wholly restricted to external factors
impinging on the individual. In these instances the inner world of the individual
may not need to be considered. Psychodynamic issues concerned with earlier
emotions and responses may be largely ignored as current behavioral
manifestations are inspected. At other times, the crisis worker is advised to
explore core developmental issues and to assess general coping skills rather
than the skills used in coping with the present crisis. These are more complex
techniques that require knowledge of psychodynamics to understand individual
responses to episodic struggles and frustrations.
Every crisis involves an individual, a family, or a community that responds in a
particular way to particular circumstances. During the crisis counseling
sessions, the worker acknowledges in words and actions, the existence of a
compelling problem that is causing distress. The focus of crisis work is on the
search for a solution to the immediate problem.
The contract for crisis counseling is usually short-term, lasting for the six- to
eight-week duration of acute crisis. The counseling sessions may vary in length
from fifteen minutes to an hour. The client and the counselor jointly decide on
how often to meet. If distress is extreme or if the client has poor impulse
control and may be destructive to himself or others, daily meetings may be
necessary. A worker may consider it appropriate to give the client a phone
number where she can be easily reached. If the client has a reliable support
network, weekly or biweekly meetings may be sufficient. During the sessions,
the crisis caregiver is actively involved but does nothing for the client that the
client is able to handle himself. Some clients may become dependent on the
nurse or other crisis
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worker, but the dependency is not too worrisome because crisis intervention
and the period of the therapeutic contract are brief.
Sometimes people working on a long-term basis with a family or individual will
observe that a crisis situation has developed. It may be necessary for a worker
to alter the approach being used and to become more active in order to
facilitate resolution of the crisis. A worker may then have to resume the
previous approach in which involvement was less intense. One way to
accomplish this is to introduce other professionals into the care plan, so that
any dependency on a worker can be gradually reduced.
For people engaged in helping clients in a crisis, a primary rule is not to make
decision for them but to became involved in making decisions with them.
Restoration of equilibrium through improved coping behavior is the maximal
goal of crisis work. A minimal goal is to help the clients return to at least
precrisis functioning levels, but there are occasions when even this lesser goal
is not achieved. Table 4-2 shows alternative outcomes in resolving crisis.
Implementation
Having assessed the proportions of the crisis and the locus of causation, the
crisis worker is able to develop a treatment plan that deals solely with external
factors or with a combination of external and internal factors. Assessment and
planning are activities that are maintained throughout crisis work, particularly
when the distress of the client has impeded these activities initially. Regardless
of the approach used, implementation of crisis work begins with goal setting
and establishing a contract. Ideally, the client and the crisis worker should
mutually agree on the goals to be reached. It is essential that these be clearly
stated so that the direction of treatment is understood and accepted. In
addition, evaluation of treatment outcomes is possible only if treatment goals
are clearly defined.
Working together, client and crisis worker agree on goals and define the
boundaries of the relationship. Baldwin (1980) described boundaries as being
definitional and contractual. Defining the problem introduces the idea of
cognitive, affective, and behavioral dysfunction in relation to the crisis.
Definitional boundaries go far to alleviate the confusion of the client and
constitute a strategy that expedites problem solving. Contractual boundaries
involve goal setting, establishing a time frame, and discussing shared
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TABLE 4-2 Alternative Outcomes in a Family Crisis
A demanding elderly woman, no longer able to continue living
alone, moves in with her married daughter and the daughter's
family.
Type of
Coping Strategy
Outcome
Solution
The daughter, her husband,
and the children discuss
relocating the mother. They Improved coping
agree that family life will go skills: Preliminary
on as usual, with all membersagreement and
taking some responsibility for planning prepare the
Functional
the mother. The daughter
family for change.
and husband share results of Future turmoil and
the family conference with
dissension are
the elderly mother. They
avoided.
discuss common
expectations.
Unchanged coping
skills: Family
The daughter tries to interact equilibrium is
with the family as if nothing preserved. The
has changed. She does this family and elderly
by placating her mother, her mother are
husband, and her children, as comfortable.
Questionable
she has always done. Her
Daughter feels
motto is "Peace at any price" entrapped by her
even if this requires
mother's demands
considerable self-sacrifice on and her family's
her part.
needs, as she often
has since her
marriage.
Impaired coping
The daughter aligns herself
skills: Family is in a
with her mother and against
state of
her family. She struggles to
disequilibrium. The
satisfy all her mother's whims
children are
and argues constantly with
Dysfunctional
enraged, and the
her husband. Eventually her
husband is
husband moves out of the
estranged. The
house; the marriage is in
mother is content,
serious trouble. The family is
but her daughter is
in crisis.
unhappy.
hope that the problem can be solved. Along with offering guidance, the crisis
worker must try to replace feelings of helplessness with optimism and
involvement. Alienation intensifies the distress of clients, and social supports
other than the crisis worker should be introduced. Expanding the support
network may consist of involving relatives and friends, or of recruiting other
professionals.
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Critical Guidelines
Restoration of function means that the cognitive, emotional, and behavioral
distortions of crisis have been corrected to the point that the client is no longer in a
condition of disorganization and disability. Restoration of function also means that
the client, however slowly, has regained energy to meet the basic demands of
everyday life and is beginning to enjoy some simple pleasures without being
overcome by guilt or regret. The crisis counselor who keeps this realistic goal in
mind should find the following suggestions useful (Weiss, 1987):
Accept the client's feelings about the current situation even if they seem excessive
or inappropriate. Offer assurance that the feelings are understandable without
commenting on how the client should feel. For example, the crisis counselor might
comment on the difficulty of making decisions or just getting through the day when
the client is so upset.
Explain to the client whey she feels so overwhelmed. Many clients in crisis wonder
why they cannot function; some of them even worry that they may be "crazy." For
example, the crisis counselor might review the sequence of events the client has
experienced and indicate that here is the reason the client feels helpless and
inadequate.
Instill hope in the client by stating that the present emotional distress need not last
forever. It can be helpful to describe gradual stages of recovery that are likely to
follow initial distress. For example, the crisis counselor might say, "After an
experience like yours many people say it takes a long time to get readjusted and
even longer before they can manage as well as they did before."
Give the client permission to recover and move toward normalcy and restored
function. Some clients feel that loyalty to a lost person or place, or resentment at
changes or injuries suffered makes recovery impossible. For example, the crisis
counselor should acknowledge that the client may proceed at his own pace, but
should not become immobilized because of guilt or anger. The counselor might also
suggest that the client not only needs to begin to function again, but has the right
to recover and move on.
Help the client interpret recovery as simply a return to effective functioning rather
than a return to the status quo. Indicate that recovery is not the same as forgetting
or forgiving, both of which may be a long time coming.
Evaluation
Although acute crisis is self-limiting, the residual effects are long-term. The fact
that severe disorganization abates within a short period complicates the
evaluation of outcomes. Restoration of equilibrium takes place
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An excellent system for classifying crises has been devised to facilitate crisis
assessment and planning (Baldwin, 1978). This classification system describes
six types of crisis, each of which moves from lesser to greater degrees of
psychopathology. As the gravity of psychopathology increases, the causes of
crisis become internal rather than external, and the approach of the crisis
worker is modified accordingly. In using this
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intent but wanted to make her ex-fianc feel guilty. At times Betty Lou had
fantasies of committing acts of vandalism on his expensive car. Reluctantly, Betty
Lou accepted her employer's suggestion that she seek help at a family service
agency. Her job depended on this ultimatum.
CategoryCausation
Plan
CategoryCausation
Class
Plan
husband.
guidance.
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smoke, Joe managed to lead his wife and small sons to safety. When he returned
for the family dog, Joe became trapped inside the trailer. The dog jumped out a
small window but Joe died in the fire. His wife, Donna, showed no signs of grief but
reacted stoically to her loss. She refused, however, to let her sons out of her sight.
They slept in the same bed with her and were no longer permitted to attend the
nursery school they had enjoyed so much. Donna moved in with her parents but was
withdrawn and uncommunicative even with them. Two months after the tragedy,
Donna showed no signs of working through her grief. Donna's worried mother asked
a trusted community nurse who had supervised the health of the children to visit.
CategoryCausation
Plan
Encourage
acknowledgment of
loss. Recognize
meaning of loss. Permit
spouse to express
painful feelings of
anger and guilt for
having survived. The
mother's
overprotectiveness of
the children is
maladaptive for
everyone concerned.
Instead of restricting
their world, mother
needs to help the
children deal with the
loss and to resume
usual activities.
Acceptance and
recovery on the part of
mother can begin with
directing her attention
to their needs as well
as her own. Crisis
intervention should
include the following
unexpected, sudden
interventions:
death is often hard to Encourage grieving
deal with because there and help Mrs. Jones
is no time for
detach from her dead
anticipatory
husband.
intervention. The
traumatic circumstances Encourage reminiscing.
of the death inhibited Permit expression of
the grief work of the
guilt feelings.
surviving spouse.
Expand social
interactions.
Promote wholesome
involvement from the
children.
Reduce phobic
restriction of children's
activity.
Clinical Example: Developmental Crisis
When Bill was a college freshman, his father died suddenly. His mother was a
homemaker who had never worked outside the home and who had depended on her
husband to make decisions
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for her. Bill's college was about five hundred miles from his hometown. He was
shocked and grief stricken by his father's death but was even more dismayed when
his mother begged him to move back home and attend a local college. Bill had
adjusted well at school and resented the prospect of becoming ''the man of the
house" for his mother. Yet he found it difficult to say "no" to her. He was able to
return to school to finish the semester, but the idea of returning home was so
disturbing that his academic standing was affected. He confided in one of his
professors, who suggested that Bill make an appointment with the counseling
service. Bill's dilemma was especially difficult because the college he was attending
was his father's alma mater. His father had been proud of Bill's college record and
had been instrumental in convincing Bills' mother that their son would benefit from
not being too close to home. Bill's mother had no real financial worries; other family
members, including Bill's married sisters, lived close to her.
CategoryCausation
Plan
lying in the traffic lane of a busy highway. A thirty-year-old male, Paul was
disheveled, mute, and very frightened on admission. Identification cards on his
person showed him to be the resident of a halfway house for chronic psychiatric
patients discharged to community care. When reached by phone, a staff member
came to the hospital to give information and reassure Paul. The staff member
stated that a few weeks before, Paul had been referred to a rehabilitation program
for vocational training. At the time he seemed eager to become self-sufficient and
self-supporting. In the program Paul's progress was excellent, and the counselors
hoped that he would learn to handle a real job. The morning on which Paul was
found lying on the
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street had been stressful for him. Another client enrolled in the program accused
Paul of stealing his lunch. A zealous counselor suggested that Paul began thinking of
leaving the halfway house and finding his own apartment. The same morning Paul
was assigned complicated work that was unlike the simple tasks he had been
performing. The accumulation of incidents caused Paul to become anxious and
confused. He left the rehabilitation building without telling anyone, walked about
aimlessly for a while, and decided that he could not meet the expectations that
others had for him. Wishing to run away or withdraw entirely, Paul lay down in the
highway. He wanted to give up and be cared for; the suicide gesture was Paul's way
of communicating his feelings of despair.
CategoryCausation
Plan
normal tendencies increased by loss of his job. She was unprepared for his violent
outburst one day when he grabbed a hunting rifle and ran from the house shouting
that he was going to take care of his enemies in city hall. Reluctant to involve the
police, Ben's wife phoned a relative. The relative immediately called the police, who
issued an alert. Ben was apprehended not far from city hall, where his stalking
movements and his rifle had already attracted attention. A police
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officer trained in crisis work was able to disarm Ben and persuade him to come into
custody peacefully. Ben's wife was notified and agreed to accompany her husband
to a medical center for his psychiatric evaluation and disposition.
CategoryCausation
Plan
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PART TWO
INDIVIDUALS IN CRISIS
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5
Children in Crisis: The Early Years
Children's griefs are little, certainly, but so is the child, so is its endurance, so is its field
of vision, while its nervous impressionability is keener than ours. Grief is a matter of
relativity; the sorrow should be estimated by its proportion to the sorrower; a gash is
as painful to one as an amputation is to another.
Francis Thompson
Any examination of the impact of crisis on the lives of children must incorporate
developmental issues relevant to them and their families. Children have
individual resources for coping with crisis, and, within the context of their
family and community, additional resources are available as well. Children's
developmental levels, however, make them potentially vulnerable to poor and
ineffective ways of dealing with crisis that family and community members may
use.
Children's individual or internal resources include established attachments to
and relationships of trust with adult caretakers. In addition, children's level of
cognitive development affects their perception and interpretation of a crisis
situation as well as their ability to express needs either by words or behavior. A
child's temperament and repertoire of past experiences, if any, in dealing with
crises are brought to bear on a current crisis. Health status is also relevant to a
child's ability to mobilize other resources.
The most thorough formulation of cognitive development in children was
offered by Piaget (1969). Knowledge of the cognitive limitations of young
children is important for counselors assisting them in dealing with the crises of
change and loss.
External resources can be arbitrarily subcategorized into those proximal and
those distal to the child. The primary proximal resource is the child's nuclear
family. Parents and siblings bring their bonds with the child and their own
history of success or failure in dealing with crisis to any new crisis situation. In
addition, the degree to which the temperament styles of parent and child mesh
also affect the parents' availability as
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As infants widen the range of their attachment behaviors, they also broaden
the cast of persons with whom they form attachments. These attachment
bonds with other adults differ from the attachment bond with
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the mother. These other behaviors appear later, and they are less strong and
less consistent than the behaviors directed to the mother. In reviewing studies,
Bowlby (1969) reiterated that the attachment to mother was not diminished in
intensity when attachment behaviors were also exchanged with other adults.
Elsewhere in the same book, Bowlby indicated that children with more intense
attachments to their mothers are in fact more likely to establish many
reciprocal bonds with other adults in their milieu.
The display of these behaviors has a fluid quality. Even in the younger infant,
there is variation within a day and from one day to another in the consistency
and intensity of demonstrated attachment. Some of the variability is accounted
for by the child's physiological state. When children are hungry, tired, unhappy
for some reason, or ill, they are more likely to cry for mother or follow and cling
to her. Until age three, children exhibit strong attachment to the mother with
great regularity. After age three, attachment behaviors occur less frequently
and with less urgency but still comprise a major part of the preschooler's
behavior. At the same time, children are more tolerant of the mother's absence
if they are with other familiar attachment figures. They may even seek
consolation from a nonhuman source-the so-called "security blanket." Litt
(1981) described such transitional objects as not being part of the child's body
and used by parents not using pacifiers and bottles for oral gratification. Many
mothers were aware of the object's functions and even had encouraged its
use. Such use had specified limitations, however. The object was used only at
bedtime or only in the house.
Disturbance of Attachment Bonds
The disruption of a bond at any stage in its existence can cause problems for a
child. Clearly, the greatest disruption is the loss of a parent through separation,
divorce, or death. When the experience of losing an adult to whom the child is
intensely attached occurs repeatedly, the child is left with a sense of being
unloved, abandoned, and rejected.
Spitz (1945, 1946) described the effects of such a disruption. In his article on
hospitalism, however, Spitz attributed these physical and mental effects to a
lack of stimulation from care-giving adults and other aspects of the
environment. He noted not only a susceptibility to illness that resulted in a high
mortality rate, but also a decline in the developmental quotients of the
children. Later it was found that the syndrome called early or anaclitic
depression improved in part with restoration of the mother to the child. The
somatic effects included susceptibility to infection and decline in developmental
progress together with weight loss and insomnia in some children. Spitz listed
other symptoms according to their increasing severity. Apprehension
progressed to sadness and
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ing that three year olds with a history of secure attachment were more likely to
express sadness at failing a task than those with insecure attachment.
Providing sensitive, responsive care figures can do much to strengthen
attachment, which for many children fosters the open expression of feelings,
positive and negative. In contrast, mothers and caretakers who fail to provide
attachment security convince their children that protest behavior will not have
the desired result of alleviating their distress. Parental disapproval of emotional
expression by distressed children has been associated with lower academic
competence (Roberts & Strayer, 1987). The crucial role of caretakers in
accepting and channeling protest behavior in children is supported by research
(Kopp, 1989).
Reciprocity persists in all interactions between parent and child, as each
influences the other. The child's variations in responsive behavior affect a
parent's responsive behavior and attitudes toward the child. At times the
helplessness and dependency of the child can elicit negative parental
responses as well as positive ones. Parents' perception of a child's needs
greatly determines their availability or unavailability to the child. If parents
ignore the impact of circumstances and context on a child's behavior, they are
less able to recognize a child's potential for change. Lacking developmental
knowledge, parents may hold expectations that are unrealistic for a child to
meet; and knowledgeable parents may lack sufficient resources to meet a
child's needs.
Children's difficulties are exacerbated in families in which the parents
themselves have been deprived, are poorly educated, and are currently
stressed. Some parents provide a chaotic and irrational home life where
parents convey the attitude that the world is dangerous and no one is to be
trusted. In a more positive light, some families offer a resourceful environment
where children learn to trust themselves and one another, and where change
is accepted as a fact of life. These families establish relationships with the
children that are characterized by warmth and readiness to help the children
deal with new situations as they arise.
Coping begins with recognizing the promising as well as the threatening
elements in a situation. The motivation and ability of a child's family to respond
creatively to life stress and change permits a child to progress developmentally,
socially, and affectively.
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conceived, she continued the pills through the first four months of her pregnancy.
She and the children's father had discussed their alternatives. They had both been
working and saving money to buy a house and get married. Postponing those plans
was disappointing but neither one wanted a second trimester abortion.
Rose, the new baby, had a cleft palate and other difficulties beyond her feeding
problems, but Valdeen had not been given a clear idea of what they were. In
addition, one doctor had said that the baby had a cleft palate because Valdeen had
taken birth control pills when she was already pregnant. Several caretakers had
indicated disbelief when Valdeen had reiterated her claim of faithfully contracepting.
Because of Rose's feeding problems, community health nursing services had been
requested for Valdeen's family. Valdeen and Becky had spent a large part of each
day at the hospital to be with Rose and to feed her. Valdeen felt the hospital staff
believed her irresponsible because of the birth control pill issue, and they had not
given her encouragement to hold and cuddle Rose. She had once been scolded for
picking Rose up soon after a feeding. When the community health nurse asked
Valdeen if anyone at the hospital had asked her how she was feeling physically or
emotionally after Rose was born, Valdeen's eyes filled with tears.
The nurse encouraged Valdeen to weep and begin to express her anger, frustration,
and grief. Valdeen was receptive to daily home visits ''to help you and Becky and
Rose all get settled in together and give you some moral support."
The nurse's initial evaluation included recognizing the stability of Rose's feeding
problems, and the greater need for Valdeen to deal with her affective issues and to
form attachment bonds with Rose. Valdeen had felt disparaged by the hospital staff
and guilty that her misuse of birth control pills had caused Rose's problems. The
nurse assessed Becky to be a well-stimulated, well-loved, and well-cared-for child.
Valdeen had carefully prepared Becky for the coming of a new sibling. The nurse
chose to emphasize the fine job that Valdeen was doing with Becky to help restore
her self-esteem. The nurse planned to monitor the reciprocity of affection between
Valdeen and Rose, and to evaluate the involvement of the girls' father, Terrence.
Despite her own fatigue and worry, Valdeen was able to draw on her experience
with Becky to make a commitment "to give my little Rose blossom what she needs."
Becky had a role as Mommy's helper and big sister. Terrence got too nervous if
some of Rose's feeding came out her nose or if she choked, but he was increasingly
helpful with Becky's care and very supportive of Valdeen.
Despite the family's rallying, at age five weeks. Rose had to be rehospitalized after
only five days at home. During Rose's tenday hospitalization, the community health
nurse actively advocated for the family with the hospital personnel, so that more
information was shared with Valdeen and Terrence. The nurse
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had also done some searching and shared with Valdeen that she had found no
evidence that birth control pills had caused Rose's problems. The physician in charge
of Rose's care later confirmed this opinion.
When Rose was discharged, Valdeen noticed a change. "She doesn't want to be
held. She cries and stiffens. If she isn't eating, she seems happier in her crib. She
won't even try to smile anymore." The nurse recognized the baby's behavior as
being the result of her hospitalization and separation from her mother. She
interpreted the behavior to Valdeen as the baby's forgetting what it was to be home
with her mother and needing to learn it again.
With that encouragement, Valdeen spent much of the next few days holding Rose,
talking and singing to her, and smiling at her. Rose continued to stiffen and cry at
first, but, by the third day, the baby would occasionally give a hint of a smile. Her
eating was also much improved.
Rose continued to improve for several days at home but was again rehospitalized.
She was again improving rapidly in the hospital and was nearly ready to be
discharged when she aspirated regurgitated formula during the night and died. The
community health nurse visited several times to help the family with grief work and
to express sadness at their loss.
After the initial numbness subsided, Valdeen and Terrence planned a modest wake
and funeral service for Rose. Becky seemed to adjust quickly to Rose's absence and
played normally. She was told that Rose had died and would not come home with
them anymore. Nevertheless, she continued to ask about Rose and when she would
come home. Valdeen surmised that Becky did not understand what being dead
meant. She decided not to cry in front of Becky.
The nurse confirmed Valdeen's appraisal of Becky's understanding and encouraged
her to answer Becky's questions with simple answers. She also advised Valdeen to
talk to Becky about her own grief and sadness because Rose died. She stated that
Becky might ask her mother if she herself or her mommy or daddy were going to
die, too. The nurse reiterated her statement about giving simple responses and
reassuring Becky that Valdeen and Terrence would not leave her.
About a month after Rose's death, the nurse's visits were discontinued. Valdeen
planned to return to her part-time job and Becky would go to her regular day care
center. The community health nurse reassured Valdeen of the nurse's availability if
questions or problems arose.
Because of the suddenness of Rose's death, the crisis was markedly escalated. The
parents were aided in their mourning by knowing the circumstances of the baby's
death and planning and participating in funeral services for her. Terrence and
Valdeen accepted both Becky's need to know that Rose had died and Becky's limited
cognitive ability to comprehend death as adults do. They also perceived the
possibility that Becky might wonder about her own or her parents' death.
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Critical Guidelines
The initial crisis arose because Rose had insufficient opportunity to become attached
to her mother. Valdeen responded well to the initial crisis. She was not prepared to
deal with Rose's depression after being hospitalized and separated from home.
Professional intervention was needed to help Valdeen cope with Rose's
deterioration.
Rose's death was a crisis for the whole family. The parents needed to work through
their grief. Additional guidance was needed to ease their feelings of guilt. They
needed developmental information in order to understand Becky's concept of death.
Since Becky was an easy-going child, the parents might have overlooked her
feelings because of their own distress.
Cognitive Development
Just as socialization begins at birth, so does learning. Infants respond to visual
patterns almost from birth. Newborns can react to sound and can localize the
direction from which sound originates. Furthermore, as is true of attachment
processes, cognitive learning involves the infant and the adult caretaker(s),
since the child's responses influence the caretaker's interactions with the child
(Thomas, 1981). Elkind (1974, 1988) described a child's attachment to
parents as the stable foundation supporting a child's entry into social and
cognitive learning. Because the contribution of significant adults is so crucial to
the development of children, it is important to know something of how and
when children learn.
Adults tend to think of children as miniature adults. They impose rules that are
too complex for children to understand and demand behaviors of which
children may be developmentally incapable.
One young mother was committed to the idea that her toddler learn to read
before entering kindergarten. Luckily, she responded to the suggestion that
coercion would be unwise. Being read to and watching her parents read would
be sufficient to instill in the child an interest in books without subjecting her to
literary forced feedings.
In keeping with the erroneous idea of the child as a miniature adult, parents
attribute adultlike understanding and intention to their young child's use of
"dirty words," swear words, expressions of contempt, or wishes that a person
were dead. At most, the child realizes that such words or phrases are powerful
in some way. This realization is based on prior reactions of others rather than
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mother required considerable discussion with the nurse to convince her that
Jason's intent was not a sexual gesture but merely to touch something shiny.
Based on a desire to raise polite, well-mannered children, parents may try to
impart rules of behavior to their young children. It does not work because the
child is not able to discern situations when the rules apply (Elkind, 1974). A
common example is the use of "thank you." The child has been given a gift;
the parent's question "What do you say?" is responded to with silence. The
parent is frustrated because the child did not learn the rule. The child is
frustrated because he cannot yet learn the rule and has annoyed the parent.
Stages of Cognitive Development
Jean Piaget was a Swiss psychologist who conducted extensive observational
studies of children in an attempt to understand their stages of intellectual and
cognitive development. On the basis of observation, interviews, and
experiments, Piaget postulated four stages of cognitive development in
children, lasting from birth to the beginning of adolescence. Although he gave
normative ages to the stages, Piaget (1969) emphasized the range of
individual differences in rates of development and therefore presented
chronological ages simply as a guide (Table 5-1).
TABLE 5-1 Piaget's Cognitive Development Stages
Stage
Age
Characteristics
Child learns about self and
Birth-18 surroundings through sensory and
Sensorimotor
months motor exploration and experience;
learns through trial and error.
Child develops language skills, acquires
18
understanding of symbols, recognizes
Preoperationalmonths-7
object permanence, learns to separate
years
and classify.
Child uses and manipulates numbers,
Concrete
8 yearsunderstands spatial relationships,
operational 11 years
learns to think logically and to reason.
Adolescent understands abstract
Formal
12 years- concepts, expands ability to think
operational Adulthoodlogically and to reason, formulates and
tests hypotheses.
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Piaget termed the first stage of cognitive development the sensorimotor stage.
During the first eighteen months of life, an infant uses her senses to learn
about the world. By means of sight, hearing, taste, touch, and smell the infant
explores her environment. Eventually she learns patterns of behaviors and
looks for ways to test and replicate these patterns, and she gradually learns to
predict actions based on the consequences of previous actions. For example,
she may learn that dropping a bottle on the floor causes adults in the vicinity
to retrieve the bottle and return it to her, an action that she finds gratifying.
Such primitive sequences of cause-and-effect behavior are the foundation for
future problem solving and lead to more complex intellectual development.
During the preoperational stage, the thinking of the young child is quite rigid
and inflexible, partly because the child is egocentric and unable to appreciate
ideas and viewpoints that differ from his own.
At this age, the child comes to realize that even though he cannot see a
hidden object or a person who has left the room, the object or person
continues to exist. Thus, he attains object permanence, the understanding that
people and objects exist apart from the self. To the child in the sensorimotor
stage, people or objects that are out of sight have disappeared permanently as
far as he is concerned. Therefore, when a toy is taken away from him and
concealed, he will not look for it. The child at the preoperational stage, on the
other hand, will search for a concealed toy, demonstrating object permanence.
Another characteristic of the preoperational stage is the use of symbols in the
child's thinking and communicating. At this stage the child realizes that a
single word or sign can represent more complex ideas and meanings. Bringing
a ball to father is an invitation for father to play with the child; putting on a
coat signifies a desire or readiness to go outdoors. Pumpkins signify Halloween
and the flag signifies one's country. From such basic signs, the child learns the
significance of symbols.
Between the ages of eight and eleven, the child is in the concrete operational
stage. During this stage the child can use and manipulate numbers and begin
to understand spatial relationships. These are the years when the concept of
moral judgment begins to develop and when the cognitive skills of the child are
burgeoning, although abstract thinking is not yet present. When asked to
explain the meaning of the proverb "Never change horses in the middle of a
stream," the child will give a literal interpretation, explaining that a rider
changing horses in the middle of a stream would fall in and get wet. The child
would be unlikely to generalize the meaning to other situations or to extract
the message that anyone who starts a project and changes the original plan
risks failure.
The fourth stage of cognitive development, the formal operational
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stage, begins at about age twelve. This is the most sophisticated cognitive
level. The individual becomes capable of abstract thinking and is able to
formulate and test hypotheses. Problem solving at this stage is sequential and
orderly, and reasoning processes are logical and usually consistent.
Childhood Concepts of Death
At the beginning of the sensory-motor period (newborn to 18 months), infants
have an innate grasp reflex with which they begin to manipulate objects. The
reflex activity undergoes progressive change by contact with objects having a
variety of different shapes, textures, temperatures, and weights (Thomas,
1981). Grasping and manipulating objects gradually becomes intentional and
selective. Elkind (1974) stated that the cognitive task of this period is the
conquest of the object. This conquest involves the transition from an object's
ceasing to exist for children unless they are in some current sensory contact
with it, to an object's existing as a mental symbol when they are not in sensory
contact with it. Thus, children of two years or less believe objects and people
do not exist unless they can be seen, touched, or heard by the child.
When children are between two and six years, they are in the preoperational
stage. They expand their use of symbols by acquiring language and beginning
to use symbolic play. For a child in this stage, an object can have only one
name. Once they have affixed a name to a person or object they are reluctant
to employ other names that are more conventional. Thus an umbrella may
continue to be called a "bumbershoot" despite corrections by parents or
siblings. Special names are consistently used to refer to significant persons or
objects.
From age two on, children ask many questions if they are permitted to do so.
By age four they want to know the origin and purpose of things around them.
"Where did it come from?" or "What is it for?" are questions they ask
repeatedly. At this age children begin to be concerned about death. "What is
death?'' and "Why do people die?" Most of these children do not see death as
final, but as a temporary state.
At some time between ages five and nine, children come to realize that death
is final. However, they also personify death and therefore, they feel that death
can be outwitted and eluded. This concept still locates death as being outside
the person. Thus, children's perception of death is gradually modified by
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are aware of personal mortality but perceive death as possible rather than
inevitable. Magical thinking is often used by children to ward off threats of
illness or injury. Some youngsters take reckless risks to master their fears. They
may accept dares and challenges that permit them to scoff at danger and deny
their growing awareness of sharing the destiny of all living things.
In explaining death to children, it is advisable to be factual and honest.
Euphemisms and evasions tend to confuse children. Statements to the effect
that "Grandpa is happier where he is now" seem strange when uttered by
weeping family members. Preparing children to deal with death can be
facilitated by candid discussion of the cyclical nature of human existence. Such
discussion is a form of anticipatory guidance that may be painful for adults but
helpful for children, whose cognitive and experiential understanding of death is
limited. When any family member dies, the reminiscing and mementos that
ease mourning for adults can be adapted to help children accept and
understand.
Entry into the stage of concrete operations occurs at about age seven or eight
and this stage persists until about age eleven. To their parents' delight,
children's intense question asking is over. Their thinking is now more adultlike
in that they can deal with two elements or relationships of a situation at the
same time. In confronting death these children can see the difference between
the inevitable death of an elderly person and the untimely death of a younger
person. Furthermore, in their mastery of recognizing classes of things, children
can complete the primary school exercise of inspecting several items and
picking out the one that does not belong-that is, the item not in the same
classification as the others.
In discussing children's cognitive ability at this stage Elkind coined the term
"cognitive conceit" and applied it to the new discovery by children that adults
can be wrong and the resulting assumption that adults must be wrong about
almost everything. Although children suppose adults to be in error much of the
time, they also believe that most adults have good intentions in spite of not
being very bright (Elkind, 1974).
Piaget's theoretical framework can also be used in trying to teach, reassure,
and care for children of various ages, whatever the setting. Knowing that a
young child cannot use or understand symbols will remind nurses to interact in
a fashion appropriate to the child's age and cognitive abilities. The use of
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Autonomy vs.
1-3
shame and
years
doubt
3-6
Initiative vs.
years guilt
present experiences
Copes with changing body
image
Searches for identity and a
place in society
18-25 Intimacy vs.
years isolation
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Temperament
Attachment processes, social learning, and cognitive development are thought
to begin at birth. Similarly, a child's temperament becomes apparent in the
neonatal period. Just as attachment behaviors are variable over time, so are
manifestations of temperament. Thomas and Chess (1977) defined
temperament as a behavioral style expressed over time. The origins of
behavioral style or temperament may lie in genetic influences as these are
influenced by social experiences. Parents and siblings, peer groups, teachers,
extended family members, and neighbors all convey environmental and familial
influences to children (Thomas, 1981).
Individuality in behaviors of newborn infants appears in the regularity or
irregularity of their eating patterns, in the intensity of motor activity, in their
responses to stimuli, and in their willingness to modify their reactions. Thomas
and Chess (1977) formulated nine traits of temperament from which they
developed three constellations of children: (1) the easy child, (2) the slow-towarm-up child, and (3) the difficult child. All three constellations may be
considered within normal limits. Not every child definitely fits into one of the
constellations and no child remains in the same constellation at all times. The
individuality of each child persists in spite of trait or temperament
categorization. The nine traits constituting temperament characteristics include
the following:
1. Level of motor activity (proportion of active and inactive periods).
2. Rhythmicity or regularity (cycles of eating, sleeping, and elimination).
3. Approach-withdrawal responses (initial response to new stimuli).
4. Adaptability (readiness to modify responses to new stimuli).
5. Responsiveness threshold (amount of stimulation needed to elicit a
response).
6. Reaction intensity (energy level of response).
7. Mood quality (proportion of positive, friendly behavior to negative, unfriendly
behavior).
8. Distractibility (alteration of ongoing activity by presence of extraneous
stimuli).
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which they perceive and influence their environment. Within the framework of
their cognitive development they can elect a different way of dealing with
environmental demands or of eventually selecting a different kind of
environment.
Temperament and Stress
During childhood children and their families encounter stressful life events,
such as illness, relocation, and the loss of a significant person through death or
divorce. Stress is also engendered in the daily operations of children and their
families through time pressures, obligations, and what Kanner et al. (1981)
termed daily hassles. A number of variables have been identified that reduce
the impact of stresses being expressed behaviorally. High levels of social
support constitute a mediating variable. Another mediating variable is
temperament, and environmental responses. Carey (1981) noted that
temperament-environment interactions are involved in such childhood
problems as colic, night waking, minor developmental delay, school
performance, and frequency of accidents and illness. They are also likely to be
factors in failure-to-thrive, child abuse, obesity, and other psychosomatic
syndromes. In a study of relationships among stress, temperament, and
behavior, Wertlieb et al. (1987) found several areas of significance. The
following temperament characteristics were associated with behavioral
symptoms in children: high activity level, low adaptability, withdrawal from new
stimuli, high intensity, unpleasant or unhappy mood, lack of persistence, and
irregularity and unpredictability of behavior. The data also indicated that
chronic stresses caused by poverty led to daily hassles that may be as stressful
to children as major adverse life events. How particular temperament attributes
place certain children at risk has not yet been clearly documented. Available
data lend empirical support to the idea that temperament is a significant
influence in the socioemotional functioning of children and in the outcome of
stress reactions. Lerner and East (1984, p. 158) wrote that "temperament may
be a quite salient moderator of a person's reactions to stressors" by interacting
"with key contextual moderators, such as social support."
Family as a Resource
The parents as caretakers of children provide them with their first and most
intense attachments, their first opportunities to manifest temperament, and
their first learning experiences. As children develop, their siblings will influence
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each child has a different family experience because of ordinal position, age at
the birth of any siblings, and sex. Younger children may model the behavior of
older siblings and of the parents. For example, Chrissie, at age two, was
frustrated with her toilet training. She could not understand why aiming her
belly button at the toilet to urinate only resulted in wet sneakers when (by her
observations) it seemed to work just fine for her daddy and big brother!
Grandparents, aunts, uncles, cousins, and other extended family members are
not merely persons with whom the child establishes additional attachments.
They are also the repository and conveyors of the family's history and
accumulated wisdom. That wisdom often relates to how problems were solved
and crises managed in the past. In addition, adult members of the family
provide access to resources, such as human services agencies or health care
facilities, to which the child alone could not gain entry.
Counseling Children
Grownups like to think of childhood as a jolly time when most parents or parent
surrogates love and protect their children. This is not always true. Even in
stable families, children inhabit an inner world of uncertainty and puzzlement,
which is aggravated by urgent maturational tasks. Because infants and young
children are so dependent on adults to attend to their needs, teaching adults
who are responsible for children about maturational tasks and developmental
stages is a primary prevention strategy. Dysfunctional behavior patterns in
children can be worsened or alleviated, depending on parental expectations.
Parents and others who do not recognize developmental time frames may
attempt to hasten or impede processes that are within the normal range.
If the behavior problems of children assume crisis proportions, practitioners can
use principles of secondary intervention. When it appears that a parent is the
instigator of the problem, practitioners can model effective adult-child
interactions. By explaining and demonstrating basic concepts of stimulus,
response, reward, and conditioning, practitioners can indicate those adult
actions that initiate, reinforce, or reduce undesirable behavior in children. The
difference between limit setting and punishment is a subtle one for parents
who rely only on scoldings and spankings to change children's behavior. It is
extremely important to show parents the value of positive reinforcement
(rewards) in eliciting improved behavior. For some parents praise is harder to
bestow than criticism. Such parents need to learn that approving gestures will
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exchanged was Mr. S.'s complaint that nothing he did satisfied his wife and that she
and the children
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"are draggin' me down, not letting me get my head above water." The children, of
course, overheard.
As the eldest son and his father's favorite, Billy thought that he had done something
wrong to make his father leave. He accepted his father's statement. He
reinterpreted the parents' discord to see himself as the cause of it, not his father's
shaky self-esteem and alcoholism. Although Billy could neither acknowledge his
father's problems nor fully accept that marital discord caused the disruption, he was
able to assimilate his mother's commitment to the children.
Billy's eight-year-old brother coped with the departure of his father by accepting the
message that Billy was "the man of the family" now. Missing his father, he followed
Billy constantly. The older boy found this a nuisance, but he tried to respond to his
brother's distress.
The five-year-old boy in the family had endless questions about his father's absence.
Because his mother became upset by the questions, the five year old turned to Billy
for comfort. The youngest child, eleven months of age, continued his usual habit of
looking and calling for "Da," especially in the evening when his father usually arrived
home from work. He persisted with this for almost two weeks after his father left.
For a much longer period he was reluctant to let his mother out of his sight and
repeatedly called to her to reassure himself of her presence.
School personnel were especially interested in the two older children. As a result,
they met regularly with a school counselor. A social worker from the local health
clinic visited the home to help Mrs. S. deal with various community agencies. The
worker was not successful in persuading Mrs. S. to make friends in the
neighborhood, but her visits and those of the nurses helped the family to feel less
isolated and abandoned.
Critical Guidelines
The mother and children in this family experienced two drastic separations within a
short period of time. There was separation from a familiar community, followed by
the father's desertion. Anxiety levels of all family members was extremely high. In
addition, the mother was overwhelmed by her new role as a single parent. In their
old community she would have access to the advice and friendship of other women.
The first consideration in working with this family was to help the mother deal with
the immediate problems. A welfare worker gave assistance so that rent was paid,
and the family received a subsistance allowance for food. A community worker was
made available to accompany Mrs. S. to a parents' meeting at her boy's school
where the school program was explained. Although she continued to be reclusive,
Mrs. S. found that the visit did reduce her fears of the unknown. Aid was given to
help the family return to their former community.
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In general, an ecological approach was used with the family. Once the survival
needs of her children were met, Mrs. S. became more receptive to explanations of
her children's feelings. Even though she chose to return to her home community, the
crisis situation became a learning experience for Mrs. S. and strengthened family
ties.
Summary
Crisis in children's lives should be examined in light of the developmentally
relevant resources available to the child for crisis resolution. Attachment,
cognitive development, and temperament of children influence and are
influenced by family reciprocity and interaction. Additionally, the concepts of
attachment and separation by their presence or absence clarify situational
precipitators of crisis in children. Theories of cognitive development and studies
of temperament in children also help to explain some of the differential
responses of children in crisis.
References
Belsky, J., and M. Rovine. "Temperament and Attachment Security in the
Strange Situation: An Empirical Rapprochement." Child Development
58(1987): 787-795.
Bowlby, J. "Attachment." In Attachment and Loss, vol. 1. New York: Basic
Books, 1969.
___. "Separation." In Attachment and Loss, vol. 2. New York: Basic Books,
1973.
___. The Making and Breaking of Affectional Bonds. London: Tavistock, 1979.
Carey, W.B. "The Importance of Temperament-Environment Interaction for
Child Health and Development." In The Uncommon Child," edited by M. Lewis
and L. Rosenbaum. New York: Plenum Press, 1981.
Elkind, D. Children and Adolescents: Interpretative Essays on Jean Piaget. New
York: Oxford University Press, 1974.
___. The Hurried Child. Menlo Park, California: Addison-Wesley, 1988.
Erikson, E. Childhood and Society. New York: Norton, 1963.
Fish, M., and J. Belsky, "Temperament and Attachment Revisited: Origin and
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6
Adolescents in Crisis: The Teen Years
We are so largely the playthings of fate in our fears. To one, fear of the dark, to
another of physical pain, to a third of public ridicule, to a fourth of poverty, to a fifth of
loneliness-for all of us our own particular creature lurks in ambush.
Hugh Walpole
For adolescents, as for younger children, developmental issues play a large role
in precipitating crises. At the same time developmental maturation may
improve a teenager's capacity for crisis resolution, especially if family support is
available. In exploring the expanded social sphere of adolescents, it is
appropriate to discuss such important factors as attachment, temperament,
and cognitive development.
Attachment
Bonds of affection between parents and child weaken somewhat during the
young person's adolescence. Nonetheless, Bowlby (1969) indicated that the
attachment persists at relatively intense levels throughout life, with individual
variations in range of intensity. Attachments with siblings in part reflect the
teen's ordinal position among the children. For example, an older teen may
take a parent surrogate role with one or more younger siblings. On the other
hand, the teen may become closer to one or more older siblings whose role
may be as mentor or guide. Teenagers form bonds with other adults that may
approach the intensity of bonds with parents. Thus, teachers, counselors, the
school nurse, neighbors, leaders of community teen groups (such as clergy),
and others in human service professions may become very accessible as
resources. Rutter (1979) tied the establishment of such bonds to successful
past attachments and the trust that results. As with prior attachments, the
effectiveness of newer attachments is predicated on the quality, strength, and
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socioeconomic status. They found that clear formal operational reasoning was
used to complete a task by 53 percent of the sample who were between
sixteen and twenty years of age. The highest display
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ranges of possibilities in dealing with any given situation. Elkind noted their
consequent difficulty in making decisions. In part, the difficulty lies with
teenagers' inability to assess the appropriateness or the priority of their
alternatives (Elkind, 1978). The dilemma is in part responsible for the young
teenagers' tendency to follow the dictates of their peer group. They may also
baffle their parents by asking for advice and then ignoring it. It is likely to
minimize confrontations if parents can
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Each stage of moral development has its own particular orientation; ambiguity
arises as individuals begin to question their present orientation stage. This
questioning is resolved as individuals move to the next stage and find that the
new orientation settles or reconciles their previous questions. If a person finds
that his present stage is not adequate to resolve a moral dilemma, he will
gravitate toward the next highest stage.
Preconventional Level
Kohlberg described the first level, or preconventional level, as one at which the
child is responsive to cultural labels of good and bad, right and wrong, but
interprets these labels in terms either of the physical or psychological
consequences of action (punishment, reward, exchange of favors) or of the
physical power of those who enunciate the rules and labels. This level
describes most children up to the age of early adolescence; however, some
adults are fixated at this level, too. At this first level, actions are judged
according to expected consequences.
Fear governs the actions of a person at stage 1 of the preconventional level
called the punishment and obedience orientation. Kohlberg's theory would
explain the antisocial actions of criminals as behaviors of a stage 1,
preconventional level. Kohlberg called stage 2 the instrumental relativist
orientation. At this stage a person decides issues based on what satisfies her
own needs and sometimes considers the needs of others. Persons operating at
stage 2 of the preconventional level perceive society as made up of others like
themselves, and they believe that if they extend help to others, they are likely
to be helped in return. Because the person at this stage believes that all
people are alike, she will begin to question why one person should have more
rights than another. Thus, stage 2 marks the beginning of a sense of fairness.
Nonetheless, self-interest remains important, and fear of authority is reduced.
To obtain compliance from persons at this stage, it may be necessary to
demonstrate how they will benefit from a given situation or transaction.
Conventional Level
The move from the preconventional level to the conventional level is
accompanied by accepting group values, and recognizing the importance of
group rules and sanctions. The personal consequences of an action are no
longer the only criteria by which to judge its goodness or morality. Instead, an
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this level group standards of conformity and loyalty are readily adopted. Most
teenagers operate at the first phase (stage 3) of the conventional level. This
helps explain their preoccupation with fads and popular heroes. Gradually, they
realize that society is composed of diverse groups whose values and customs
must be considered. This realization causes them to progress to the second
phase (stage 4), at which time they respect authority and order. They tend to
assume that no person or group is above the law; Kohlberg declared that most
adults remain fixed at this stage of moral development.
Postconventional Level
Before advancing to this level behavior is guided by fear of punishment (stage
1), desire for rewards (stage 2), group norms (stage 3), or adherence to rules
and laws (stage 4). At this last level individuals make a distinction between
public welfare and personal freedom. They believe the existing laws may be
questioned, and that the status quo may be challenged without creating
anarchy. At the same time laws cannot be discarded simply because they are
personally objectionable.
This last and highest stage of moral development encourages internalized
respect for honor, justice, and the rights of all. The individual operating at this
level will go far to avoid violating self-imposed principles, even at the cost of
unpleasant consequences, such as imprisonment or social ostracism. In
Kohlberg's view, this stage is an ideal seldom reached.
Critics of Kohlberg's work assert that he did not give equal attention to both
sexes, and that he considered the word child to refer only to boys. Gilligan
(1982, 1983) proposed that there are two modes of moral reasoning. One
mode, as described by Kohlberg, is based on logic, justice, and rights; the
other is based on caring, circumstances, and relationships.
Gilligan has concluded that men and boys are apt to define themselves in
terms of autonomy and achievement, whereas women define themselves in
terms of relationships. In her ongoing work Gilligan has found that many girls
emerge from adolescence with a poor self-image, and lowered expectations for
themselves. Among girls, race seems to be a significant factor. More black girls
have been found to be relatively self-confident in high school compared with
white and Hispanic girls. White girls lose their self-assurance earlier than
Hispanic girls. Without making broad generalizations, Gilligan states that it is
during the teen years that girls begin to doubt themselves. At eleven years of
age they are full of self-confidence, but by age fifteen or sixteen they have
begun to doubt themselves (Gilligan et al., 1989).
Gilligan's work is relevant to crisis among adolescents for two reasons. (1) It
acknowledged the complexity of the many facets of human
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and normal increase in teens' interest in their body changes and sensations,
including exploration by masturbation. The coach reassured him that he was
growing normally and indicated that his penis would start to grow larger about
the time he noticed hair growing in his genital area.
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often involving group activities. Chilman (1977) stated that sex play occurs
fairly frequently in groups of boys aged eight to thirteen. Their activities include
mutual masturbation, exhibitionism, and voyeurism. In early adolescence,
about 10 percent of boys may engage in sex relations at least once with
another male. However, only about 3 percent
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engage in long-term homosexual relationships. The data for girls indicate that
about 5 percent are involved in early adolescent homosexual activity, with less
than 2 percent participating in long-term involvements.
Research studies have tried to evaluate differences between adolescent girls
who are sexually active and those who are not. A relationship has been
established between adolescent sexual activity and the use of alcohol, tobacco,
and other drugs (Franklin, 1988). A study done in California, which controlled
for race of the subjects, found that sexual activity was significantly related to
race and socioeconomic status (SES), with black and low-SES girls more likely
to be sexually active (Gibbs, 1986). Interestingly, white females were more
likely to use drugs but less likely to be sexually active. A conclusion was
reached that race, going steady, and cigarette smoking were the strongest
predictors of early sexual activity.
A number of investigators agree that smoking and drug abuse may have
unique importance during adolescence for the following reasons:
This type of behavior is an attempt to grasp otherwise unattainable goals.
The behaviors are learned ways of handling personal frustration and
anticipated failure.
The behaviors express rejection of more conventional society.
The behaviors ease developmental transition and signify membership in the
peer subculture.
It is apparent that teenagers who begin to smoke and drink at an early age
tend to adopt other so-called adult activities in the teen years (Franklin, 1988;
Zelnik & Kantner, 1980). Family structure is another factor in teenage
pregnancy since girls in father-absent households are more likely to become
pregnant than girls in two-parent homes (Buchholz & Gol, 1986).
Other studies indicate that for girls the motivation stems from a wish to please
the sexual partner, although they apparently experience less sexual pleasure.
Ladner (1971, p. 209) attributed the early sexual activity of low-income black
girls to their search for a feeling of ''belonging and feeling needed by their
boyfriends ... and a sense of identity and utility." Quay (1981) suggested that,
especially for girls, dependency needs, unhappiness at home, and a wish for
affection underlie early coitus and pregnancy.
Piaget (1969) asserted that adolescents are undergoing a shift from concrete
to formal operational thinking. Consistent contraceptive behavior demands
thinking on the level of formal operations. Not all adolescents are capable of
abstract thinking on the causes and consequences of their actions. Only those
adolescents who have advanced to this level of
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thinking can prepare for sexual encounters, avoid impulsive coitus, and acquire
and apply the information needed for responsible sexual behavior.
An adolescent still at the stage of concrete operations has limited
understanding of the meaning of the ovulation, conception, and childbirth
processes. Another consequence of being in the concrete operational stage is
extreme egocentrism, which allows the adolescent to feel special and
invincible. This personal fable of their own uniqueness reinforces adolescent
attitudes that bad things happen to other people but not to them.
The male partner's role is an essential factor in considering contraceptive
behavior among adolescents. Zelnik and Kantner (1980) reported that about
40 percent of sexually active females depend on male use of contraceptives.
Among the many different reasons teenagers gave for getting pregnant were:
(1) wanting a baby, (2) holding on to a boyfriend, (3) thinking it might be
"fun" to have a baby, (4) punishing her parents, and (5) wanting to be loved
by the baby (Resnick et al., 1990).
Programs at the level of individuals, families, and communities must be
developed if the teenage pregnancy rates are to be lowered. Attention must be
paid to adolescents prone to early initiation into sexual activity. This means
identifying families most likely to foster precocious sexual activities in their
adolescents, and understanding community norms that reinforce patterns of
early sexual activity and parenthood. Hofferth (1985) conducted a literature
review on the impact of family planning programs on the sexual activity,
contraceptive use, and fertility of adolescents. She concluded that adolescents
engaged in smoking, drinking, or drug use, and adolescents with poor
academic performance were most at risk and should be a target group for
primary prevention. Ideally, such programs would help girls identify educational
and vocational goals, and assist them in comprehending the limiting effects of
adolescent motherhood. Outreach efforts of these programs would try to
involve males. Franklin (1988) adds that the widespread problem of
joblessness should be part of any agenda addressing teenage pregnancy. In
light of this, a worthy goal of any program trying to reduce teenage pregnancy
is to decrease high school dropout rates and enable more adolescents to be
competitive in the labor force.
A number of school districts across the country have established student health
clinics within high schools, where students have access to services that they
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interview for the study. Infrequent intercourse may in turn partly explain the
trend away from birth control pills to less reliable contraceptive methods, noted
by Zelnik and Kantner (1980). The shift to less reliable contraception or to no
contraception may also reflect decision making based on the personal fable.
They saw teens as applying the laws of probability to their own sexual activity
in an
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ignorant way, believing pregnancy was not possible because "we only did it a
few times." If intercourse has not resulted in pregnancy, teenaged women may
then surmise that they cannot get pregnant.
Follow-up studies indicate that programs that assist young mothers to
complete their education are associated with increased use of contraception
and fewer subsequent pregnancies (Phipps-Yonas, 1980). Elective abortion
tends to be the recourse of older pregnant females and of those in higher
socioeconomic classes. Decisions either to abort or to carry pregnancy to term
seem to be related to influence from the mother or boyfriend. Not infrequently
the individual who succumbs to pressure from others for abortion will soon
conceive again and carry the subsequent pregnancy to term. In the short run,
those who have been persuaded to abort seem less able to cope with the
stress of the procedure than those who choose freely. In general, anxiety and
depression are more associated with delay than with abortion itself. There is,
however, no easy way to deal with the crisis of an unwanted and unexpected
pregnancy at any age.
The rising incidence of teenage pregnancy has led to federal, state, and local
programs that focus on pregnancy prevention, pregnancy decision making, and
postpregnancy outcomes. One strategy has been to suggest adoption as an
alternative to abortion or teenage motherhood. The majority of respondents in
a retrospective study cited external reasons such as pressure from parents,
physicians, and social workers as the primary reason for placing the children for
adoption. A small minority cited personal reasons such as age, education, or
unpreparedness for parenthood as major reasons for adoption (Deykin, et al.,
1984).
In a study of adolescents who carried their pregnancy to term, a majority
described abortion as morally unacceptable or against their religious faith. A
small minority said that it was "too late" for an abortion by the time the
pregnancy was confirmed, or by the time the teenager acknowledged it.
Resnick et al. (1990) warned that the complexity of pregnancy decision making
does not lend itself to simple explanations. Family composition, social status,
and future aspirations are a few of the external influences on pregnancy
decision making. In addition, a host of internal influences such as moral and
cognitive development, along with subconscious dynamics, are also present.
Practitioners can clarify the dilemma of pregnant adolescents by providing
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behavior and convince women that biology need not be destiny. When
counseling unmarried pregnant females, it is not advisable to be directive
about such decisions as marrying the father or terminating the pregnancy.
Marriage between the pregnant mother and the putative father is usually a
middle-class option, with the majority of lower-class expectant mothers
choosing single parenthood.
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make the decision. The consequences of each course of action were discussed.
Within the first trimester a decision was reached that the pregnancy be terminated.
Sarah's aunt and mother accompanied her to the clinic for the procedure, and Sarah
went to her aunt's home for aftercare.
After the procedure was done, the nurse again discussed various contraceptive
methods with Sarah, adding that, although legally permitted, abortion was the least
acceptable method of birth control from a psychological, physiological, and ethical
standpoint. Moreover, reliance on abortion to undo the results of thoughtless sexual
acts encouraged political and public dissent.
An appointment was scheduled for the time Sarah would have delivered had she
chosen to continue the pregnancy, a time when women who have undergone
spontaneous or induced abortion usually need help with their feelings. At this visit,
Sarah seemed older and quieter but not regretful of her choice. The relationship
with her boyfriend had survived the ordeal of unwanted pregnancy. Sarah now used
contraception consistently and had shared her experience with her girlfriend in order
to help her be more realistic about sexuality.
Critical Guidelines
Many esoteric explanations have been proposed for the rising numbers of
inappropriate and unplanned pregnancies in modern life. Some young women
undoubtedly view pregnancy as a way of negotiating a rite of passage into
adulthood, only to find themselves isolated from their peers and alienated from their
families. Among young parents there is rarely much awareness of the long-term
responsibilities of parenthood nor realistic planning for the future. Time factors
compound the difficulties present in this extreme crisis of decision. If time
constraints are pressing, frequent preliminary sessions should be arranged in order
to promote decision making. A model for conflict resolution has been formulated to
be used in deciding pregnancy outcome (Bracken et al., 1978). In this model,
cognitive and affective activities are identified:
Acknowledgment of the pregnancy and the emotions it evokes.
Formulation of alternatives and possible actions.
Consideration of merits and disadvantages of various alternatives.
Commitment to the decision made, with opportunity provided for emotional
catharsis.
The initial counseling sessions should deal with issues categorized as retrospective,
immediate, and prospective. For each category certain relevant questions should be
asked:
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Retrospective Issues:
What were the circumstances surrounding the pregnancy? Is the pregnancy the
result of rape or incest? Were the partners involved in a long-term relationship?
Immediate Issues:
Is the putative father still involved with the expectant mother? What are his feelings
about the pregnancy? Is he pro-abortion, anti-abortion, or neutral?
What is the most compelling reason for considering abortion? Fear of parenthood?
Financial worries? Commitment to career goals?
What is the most compelling argument against abortion? Religious beliefs? Parental
disapproval? Other emotional entanglements?
Prospective Issues:
What are the most formidable aspects of carrying the pregnancy to term? What
would it be like to deliver the baby and keep it? What would it be like to deliver the
baby and give it up for adoption?
What are the most formidable aspects of abortion? Physical fears? Emotional
consequences? Anxiety? Guilt? Remorse? Relief?
Decisions about sexuality are difficult for adolescents, especially if they believe they
have no understanding adults to help them. Because they tend to distrust adults,
adolescents are susceptible to misinformation circulated by peers. Unsure of
themselves, young people are subject to exploitation, and at times sexual activity
may be used by young women to manipulate and coerce young men.
An instance of such manipulation occurred in the life of Bill, an eighteen-year-old
mechanic. Debbie, a girl Bill dated, became pregnant and claimed the baby was his,
although she had other sexual partners from time to time. Bill wanted "to do the
right thing" but was reluctant to marry Debbie. As a result of her entreaties, Debbie
and Bill began to live together. When the baby was born, Bill tried to live up to the
responsibilities he had accepted but by the time the baby was six months old, Bill
felt trapped. He and Debbie argued about everything; she was an indifferent mother
and they disagreed about how to care for the child. Bill's job paid poorly, but Debbie
refused to consider taking a part-time job to help with expenses. Difficulties were
made worse because Bill suspected that Debbie had used her pregnancy to "get
what she wanted-a dependable wage earner like me." Furthermore, Bill had come
to believe that Debbie cared very little for him or for the child. His depressed state
of mind came to the attention of his employer, who valued Bill's services. Bill's
employer advised him to seek counseling, along with legal assistance to ascertain
his rights and responsibilities toward the child, whom he loved.
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Identity
Adolescence is generally recognized as a turbulent period of life. The individual
is maturing physically, intellectually, socially, and sexually at a rapid rate. In an
interval of about seven years, the individual travels the territory between
childhood and incipient adulthood. It is a strange and intense journey over an
unknown terrain (Erikson, 1968). Most adolescents progress without undue
difficulties, although the period is often stressful for parents as well as children.
Perhaps the major task for adolescents is the establishment of identity as they
move away from their family of origin. In the process of establishing a separate
identity, they sometimes acquire problematic behaviors. The task of creating a
separate identity is complicated by the fact that most adolescents must
accomplish it while continuing to live with their family of origin, on whom they
are likely to be financially dependent. At this point the adolescent is asking
himself such existential questions as "Who am I? What shall I do with my life?
Where will I fit in?" While the adolescent is asking these questions and
differentiating from his family, his peer group assumes a position of great
importance. Fads, stereotyped activities, and group-approved behavior become
highly influential, often more than parental viewpoints.
Childhood identifications achieved by exposure to roles modeled within the
family precede identity formation (Erikson, 1968). Teenagers selectively take
on and leave out parts of those roles and combine the parts in new ways under
the influence of their social milieu. Sider and Kreider (1977, p. 844) defined
identity as "the adolescent's awareness of who he is as well as his perception
of the assessment of others regarding who he is." A positive identification with
parents and participation in the process of family decision making are among
the most salient factors in the establishment of a strong identity. As we have
seen in other aspects of development, the tempo of progress toward identity
formation may be variable.
No one has written more sensitively on the process of identity formation and
identity confusion than Erikson (1963, 1968), who formulated the concepts of
identity foreclosure and moratorium. Foreclosure consists of a premature
stabilizing of identity that results from the demands of others rather than selfdiscovery. The lure of foreclosure for teenagers lies in their avoidance of the
work of choosing among a range of options the life style, vocation, values, and
relationships that are most meaningful to them. There is potential for crisis in
premature foreclosure. The young person who ignores internal aspirations and
impulses, and yields to external forces tends to eventually become quite
dissatisfied with life.
For some young people, affiliation with causes and cults of one kind
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Critical Guidelines
Erikson (1968) indicated the usefulness of a psychosocial moratorium, which he saw
as a prolongation of adolescence. Ricks (1980) described the moratorium as keeping
one's options open. The adolescent avoids commitment to long-range components
of identity. He experiments in affiliating with different groups and in assuming
different identities within those groups. Ricks stated that the maintenance of the
moratorium is often a conscious effort for adolescents in college.
Critical Guidelines
Jenny herself was satisfied with her decision, and the family conflict abated. There
were even times when she and her father could discuss legal matters without
becoming enraged at each other. In effect, Jenny had resolved a maturational crisis,
even though the resolution was a stormy, tumultuous time for the family. She had
challenged her parents' outlook on politics,
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religion, and occupational choice. The sessions with her parents were difficult for
everyone, but the questioning process Jenny undertook was important to her
identity achievement as she identified and became committed to a value system of
her own. The sequence Jenny followed in her search for identity can be summarized
in six steps:
1. Group influences at college
2. Challenge to family values
3. Acquisition of new values
4. Family crisis
5. Commitment to individual values
6. Achievement of individual identity
Body Image
Most adolescents are intensely preoccupied and concerned with their body
image. They monitor the somatic changes in themselves, and make
comparisons with the bodies of peers and with the physical ideals of society. In
some adolescents, especially females, attention to one's body takes on
compulsiveness that far exceeds the established limits of normalcy. One
particular expression of body image distortion is the condition called anorexia
nervosa.
Anorexia nervosa is a physiological disorder, psychogenic in origin, that is
accompanied by self-induced dieting that eventually exceeds the boundaries of
conscious control and becomes compulsive. The syndrome includes episodes of
fasting, gorging, vomiting and purging, a compulsive preoccupation with food,
weight, and dieting that is demonstrated in a never-ending struggle with the
environment and with persons in the environment.
The anorectic young woman believes that there is little she can do to
experience feelings of mastery, so she looks for one area that she can control.
Ultimately she discovers this mastery by controlling what she eats. As the
disorder progresses she no longer experiences sensations of hunger yet
continues to be preoccupied with preparing and discussing food. Most
anorectic persons are high achievers in school and display compulsive
behaviors regarding academic achievement.
Bruch (1979) insisted that the anorectic is as obsessed with food as the obese
person, and that fasting and overeating are symptoms of the same disorder.
Brumberg (1990) explained that cultural forces send contradictory messages to
adolescent girls, who comprise the majority of anorectics. On one hand, they
are confronted with an abundance of food and encouraged to enjoy it. On the
other hand, they are told to control their bodies by means of dieting and
exercising. In Western countries the search for thinness is unending. The
disorder known as anorexia often begins with an effort to lose a few pounds
that eventually gets out of control.
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develop better feelings about herself, and reinforces belief that she has the
power to change her behavior.
Besides individual counseling, support or self-help groups are beneficial.
Bulimic persons are accustomed to using deceit and secrecy in their dealings
with others, partly to hide the behavior of which they are ashamed.
Establishing trust with these clients and helping them to trust other people are
appropriate therapeutic goals. Behavior modification may be used to change
eating habits by substituting other activities for binging and vomiting. Cognitive
therapy to help correct the emotional, behavioral, and thought distortions that
perpetuate the cycle is also relevant for these clients.
Counseling Adolescents
Adolescence is a period when malleable, tractable children often become
rebellious and challenging. It is essential, then, to differentiate the normal
turbulence of adolescence from actual crisis. In a true crisis situation, family
equilibrium is so threatened that outside intervention is usually necessary.
Adolescent crises may be classified as follows (Dixon, 1979).
1. Inability to meet and resolve some developmental task, frequently related to
sexuality, identity, or body image.
2. Inability to accept or adapt to rules and demands of society.
3. Inability or unwillingness to accept family rules and values.
As a general rule, permission from one or both parents is a requirement for
offering professional counseling to an adolescent. An exception to the rule is
school-related problems appropriate for school personnel to handle. Because
adolescents struggle between dependence and independence, the counselor
should endeavor to seem neutral. Without siding with adults in the picture nor
succumbing to adolescent manipulation, the counselor tries to build rapport.
This is sometimes met with resistance on the part of the adolescent, but the
counselor facilitates rapport with supportive behavior and a willingness to listen
to all sides, especially to the adolescent whose feelings may have been
discounted until now.
The counselor also tries to reinforce reality testing. This includes helping the
adolescent distinguish what is actually happening (objective perception) from
what he believes is happening (subjective interpretation). Since the adolescent
may initially resist the correction of cognitive errors, such corrections should be
made after a trusting relationship has been established. By maintaining
neutrality and objectivity, the counselor can mediate between society and the
immature impulses of a troubled adolescent. Because adolescents are at the
mercy of their impulses and because their self-image tends to be fragile,
counselors must
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be alert to the possibility of destructive acts the adolescent may direct toward
the self or other people. Extra caution is needed in assessing impulse control
and destructive potential of the adolescent. Supervision and consultation are
advisable when the counselor is relatively inexperienced. In doubtful instances,
referral to more traditional therapeutic modes is indicated.
Summary
Adolescents experience many changes in their relationships with themselves
and with others. The emerging ability of adolescents to make decisions based
on abstract thinking is often questionable. Adolescents experience considerable
difficulty in the realm of moral judgment. Current investigations seem to argue
for the existence of two modes of moral decision making: one that reflects
Piaget's "normal logic," and another that acknowledges the influence of
context and interdependence on thought and decision. Additional research
points to the widespread inconsistencies, fantasies, and apparent
irresponsibility that adolescents manifest in regard to sexuality.
The search for identity causes some teenagers to select a negative identity that
opposes accepted values, while others accede to pressures to conform. In any
case, a potential for crisis is present when adolescents eventually become
dissatisfied with a life based on external demands. A psychosocial moratorium
in which crucial decisions are deferred for a time can be a useful expedient
during the adolescent years, even though the end of the moratorium may
reactivate a developmental or existential crisis. Adolescents are often conflicted
about such issues as identity, sexuality, and body image; any of these issues, if
unresolved, may precipitate a crisis.
References
Bellack, J.P., and B.J. Edlund, (edited by). Nursing Assessment and Diagnosis
2nd ed. Boston: Jones and Bartlett, 1992.
Bowlby, J. "Attachment." In Attachment and Loss, vol. 1. New York: Basic
Books, 1969.
Bruch, H. The Golden Age: The Enigma of Anorexia Nervosa. Cambridge,
Massachusetts: Harvard University Press, 1979.
___. "Anorexia Nervosa: Therapy and Theory." American Journal of Psychiatry
138(1988): 12-14.
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Development, 1985.
Kohlberg, L. "Moral Development." In Encyclopedia of Social Science. New
York: Macmillan, 1968.
Kohlberg, L., and C. Gilligan. "The Adolescent as Philosopher: the Discovery of
Self in a Postconventional World." Daedalus 100(1971): 1051-1086.
Ladner, J. Tomorrow's Tomorrow: the Black Woman. New York: Doubleday,
1971.
Marcus, D., and M. Weiner. "Anorexia Nervosa Reconceptualized from a
Transactional Perspective." American Journal of Orthopsychiatry 59(1989):
347-353.
Newman, B., and P. Newman. "The Concept of Identity: Research and
Theory." Adolescence 13(1978): 157-166.
Offer, J., and D. Offer. "Sexuality in Adolescent Males." Adolescent Psychiatry
5(1977): 96-107.
Phipps-Yonas, S. "Teenage Pregnancy and Motherhood." American Journal of
Orthopsychiatry 50(1980): 403-431.
Piaget, J. The Origins of Intelligence in Children. New York: International
Universities Press, 1969.
Quay, H.C. "Psychological Factors in Teenage Pregnancy." In Teenage Parents
and Their Offspring, edited by K. Scott, T. Field, and E. Robertson. New York:
Grune and Stratton, 1981.
Resnick, M.D., R.W. Blum, J. Bose, M. Smith, and R. Toogood. "Characteristics
of Unmarried Adolescent Mothers: Determinants of Childrearing Versus
Adoption." American Journal of Orthopsychiatry 60(1990): 577-584.
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Ricks, D. "A Model for Promoting Competence and Coping in Adolescents and
Young Adults." In Social Competence of Children, edited by M. Kent and J.
Rolf. Hanover, New Hampshire: University Press of New England, 1980.
Rutter, M. "Protective Factors in Children's Responses to Stress and
Disadvantage." In Social Competence of Children, edited by M. Kent and J.
Rolf. Hanover, New Hampshire: University Press of New England, 1979.
Sider, R., and S. Kreider. "Coping with Adolescent Patients." Medical Clinics of
North America 61(1977): 839-854.
Tanner, J.M., and P.S. Davies. "Clinical Longitudinal Standards for Height and
Height Velocity of North American Children." Journal of Pediatrics 107(1985):
317-329.
Thomas, A. "Theory and Review: Current Trends in Developmental Theory."
American Journal of Orthopsychiatry 51(1981): 58-69.
Zelnik, M., and J. Kantner. "Sexual Activity, Contraceptive Use and Pregnancy
among Metropolitan Area Teenagers." Family Planning Perspectives 12(1980):
230
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7
Adults in Crisis: The Early Years
The art of living does not consist in preserving and clinging to a particular mood of
happiness, but in allowing happiness to change its form without being disappointed by
the change.
Charles Langbridge Morgan
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Goleman (1988).
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her to greater efforts and increase her participation in therapeutic activities for
the child.
In the absence of definitive research, Ersek (1992) found empirical evidence
that client's misperceptions often are relinquished in time, even without
constant reality orientation. It is not necessary to adopt a frontal,
confrontational style in addressing illusions or denial. In most instances all that
is required is consistent but fairly gentle reminders of social and circumstantial
reality. Such data, as are available, suggest that most people do not require
intensive attacks on defensive misperceptions of reality maintained through
denial and illusion. In assisting individuals to readjust their misperceptions of
reality, Ersek (1992) made the following suggestions.
Reality is defined within a social context and the social reality of one person
often differs from that of another.
Some illusions and some manifestations of denial may be adaptive under
certain conditions.
Reality orientation may not always be needed, especially if reality
misperceptions are not blatant, and permit problem solving to proceed.
Experiencing a supportive rather than a confrontational relationship helps
individuals to redefine reality, discard illusions, and decrease denial.
It is usually more effective to explore specific misperceptions than to argue
against them.
In correcting misperceptions, the counselor should include suggestions on how
to maintain accurate, but still optimistic, reality perceptions.
Reality misperceptions should not be equated with gross distortions. Many
healthy people resort to illusion and denial in everyday life. These widespread
coping means may impede or advance problem solving.
Behavior Patterns
Reisman (1973) described people as being inner directed or other directed,
noting that many individuals need to have their accomplishments consensually
validated by other people. As adults move from early to maturing adulthood,
many of them feel a mounting desire to win recognition and success. Motives
and ambitions vary, so that the son of a news reporter may try to become a
great writer either to surpass his father or fulfill his father's dreams. The
daughter of a singer may try to emulate her parent's achievements or refuse to
compete in the same field for fear of failing. Large numbers of individuals are
single-minded in their striving for advancement, subordinating personal
commitments to career de-
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mands. In contrast, other persons who are less avid for success may fear being
outstanding and choose instead to remain in a familiar niche, not fully content,
perhaps, but secure. For these individuals, safety and conformity are chosen
over risk and accomplishment.
The climate in which contemporary people live and work contains many
contradictions. Traditional values teach the importance of philanthropy and
social conscience, but aggressiveness and competitiveness are greatly
rewarded. Popular commitment to individual freedom is refuted by
institutionalized repetition or the imposed monotony that thrives in educational
and industrial settings. Horney (1937, 1945) described multiple conflicts
originating in society that are internalized by many individuals and expressed in
rigid maladaptive behavior patterns, identified as follows:
Dependency patterns. This individual adopts a submissive, compliant attitude
to obtain acceptance and approval. Since the overtly dependent person
engages in an unending search for emotional supplies from others, there is
movement toward social interaction.
Domination patterns. Like the overtly dependent person, this individual is
motivated by conflicted dependency needs that are denied or repressed from
conscious awareness. Basic dependency needs are further distorted by
adopting controlling or authoritarian behaviors.
Detachment patterns. This individual uses the defenses of intellectualization
and isolation to avoid emotional involvement. There is little inclination to seek
domination or acceptance, for these behaviors would require closeness that the
detached person cannot tolerate.
Decision Crises
The age at which adolescence ends and adulthood begins is subject to wide
variation. Some individuals marry or become job holders and parents before
reaching the age of twenty, thereby avoiding the postadolescence stage that
Keniston (1974) characterized as youth. Other individuals, chronologically the
same age, remain students, dependents, or rebels well into their twenties.
Despite these differences, young adults, whether socially backward or
precocious, confront a series of choices whose outcome will affect their whole
lives.
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previous years these choices were limited. The choice of whom to marry was
restricted to persons who were available, and acceptable to family and
community. Nowadays choices are less concerned with whom to marry than
whether to marry, even though a great majority of Americans do marry at least
once. With sexual expressiveness freed of involuntary procreation, there is little
need to marry merely to avoid sexual
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Occupational Stresses
Even for individuals who work merely to subsist, there are inescapable facts
about being a working member of society. Regardless of occupation, an
unavoidable amount of stress is experienced, and the occupational
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monotony, and correlation of assembly line work with coronary disease has
been reported (McLean, 1980). Piecework or production work has also been
shown to be stressful. One study of on-the-job stress required female office
workers to perform their usual tasks for a period of four successive days. On
the first and third days the women were paid on a piecework basis that
increased their wages as productivity rose. The other two days were control
days for which customary wages were paid.
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On experimental days productivity rose 114 percent, but there were many
subjective complaints of physical discomfort. On these days average adrenaline
and nonadrenaline excretory levels of the workers rose 40 percent and 27
percent, respectively. In other work settings piecework has been linked to
higher accident rates.
Two variables that transcend occupations and contribute to job-related stress
are quantitative and qualitative overload. Quantitative overload refers to having
too much to do, whereas qualitative overload refers to having tasks that are
too difficult to accomplish. An investigation of quantitative overload showed
this variable to be significantly related to excessive drinking, decreased selfesteem, low motivation, and high absenteeism. Qualitative stress results when
there are discrepancies between what workers think the job should entail and
what is being asked. Workers who are unsure of their specific assignments
experience tension, dissatisfaction, and loss of confidence. Behavioral
disturbance has been observed in situations in which assigned responsibilities
either exceeded or did not measure up to the capacity of the worker.
Occupational stress may be a contributing factor in various psychophysiological
disorders, and the crucial issue is the interaction between temperament and
the work situation. Any job that is characterized by qualitative and quantitative
overload, rapid change, and unrealistic performance standards will be stressful
for most people, although the perception of events and the responses are
individualized. Other predisposing factors include heavy responsibilities, altered
responsibilities, and discrepant sociocultural expectations. Cardiac illness often
develops not at the peak of a stressful situation, but after maximum pressure
has subsided. This is the point at which the individual who has managed to
adapt to rigorous demands becomes aware of feeling exhausted. During this
time of fatigue and lassitude, blood viscosity increases and clotting time
decreases, and cardiac output and oxygen consumption are reduced, all of
which heighten susceptibility.
Occupational Change
Fulfillment in work can be a source of renewal and energy that facilitates the
performance of intrafamily roles. There are times, however, when work is not
fulfilling either because conditions of employment are unpleasant or because
the individual wants additional psychological or financial compensation. The
timing of occupational changes must be considered in light of their impact on
the entire family. A distinction should be made between voluntary changes the
individual seeks and involuntary changes thrust on the individual, since these
variables influence family acceptance of occupational change. Locating the
proposed change within the family life cycle may help sort out family attitudes
toward occupational change.
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Analysis of Risks
Judicious decision making requires examination of the amount of risk
acceptable to individuals considering occupational change. Some persons are
strongly attracted to risk taking while others shrink from it. Just as individual
tolerance of risk varies, so do individual ideas about what constitutes risk. An
actress who epitomizes poise and elegance may suffer torment when
interviewed by members of the press. A corporate executive may implement
policies with far-reaching effects but be unable to share his innermost feelings
with anyone. Except for the rare individual who finds risks invigorating, most
persons would rather deal with small risks. Individuals thinking of beginning a
new venture often become unsure and seek help to resolve their doubts. For
example, an ambitious young man conflicted between continuing as a junior
member of a respected law firm or establishing his own practice may find
himself in a state of crisis. On one hand, there is steady income, slow but
predictable progress, and the prestige of belonging to an established firm.
Balancing these factors, on the other hand, are autonomy and the prospect of
larger earnings and greater professional recognition.
When counseling individuals who are considering occupational change, the
crisis worker might begin by reviewing the risks involved. This review can be
facilitated by partitioning the project into segments that can then be
approached singly. If the implications of the new project are overwhelming,
taking time to analyze them is essential. Gathering information from a number
of reliable sources, compiling a balance sheet of advantages and
disadvantages, and exploring the multiple ramifications of the project are basic
methods of evaluating risks. The following relevant facts should be considered
in the decision-making process:
For some individuals lack of meaningful work may produce depression or even
contribute to the onset of physical illness.
Job satisfaction is a factor contributing to health and well-being, although
overcommitment to work can be deleterious.
Vocational advancement may be a cause for celebration but also for
performance anxiety.
Jobs that require frequent absence from home may cause marital discord or
disturbed parent-child relationships, especially if the stay-at-home spouse is
resentful.
The idea of success is pleasant to contemplate, but the following questions
should also be asked in reviewing the possibility of failure: If the new venture
fails, how far reaching and disastrous will the consequences be? What are the
attitudes of other family members, especially the spouse? If progress is slow,
will the spouse be an ally or a saboteur?
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What criteria have been established to measure success or failure? What time
frame has been agreed on? If failure does result, what options remain open?
Examining risks and taking a deliberate approach is advantageous even if the
result is postponement or a negative decision. Analysis of risks can be used to
delineate hazards, reduce anxiety, and moderate the subjectivity that often
accompany occupational change in middle adult life.
There are marked gender differences in occupational choices. Most women
who enter professions become nurses or teachers, and the greater the prestige
of a field, the more likely it is to be dominated by men. Women who aspire to
high achievement are usually only children or oldest children without male
siblings. In the absence of sons, parental ambitions tend to be implanted in
daughters, especially if the mother values or models female achievement. At
present, the women who fills a traditional homemaker role and the career
woman are equally likely to have problems. Often the full-time homemaker
suffers from low self-esteem, which causes her to have a negative image of
herself, her husband, and her children. A different adjustment is made by the
career woman, who resolves her doubts about her own competence by
adopting a counterdependent posture. This woman exhausts herself in her
attempts to be a perfect wife and mother as well as a successful career
woman. The underlying cause of these behaviors lies in the inability of many
contemporary women to resolve their conflict between the merger self and the
seeker self.
Psychoanalytic theory views human beings as beset by two opposing drives,
notably the urge to fuse or merge with another, countered by a contrary urge
to remain individual and separate. In a lucid explanation of these two opposing
tendencies, Sheehy (1976) labeled one the Merger Self and the other the
Seeker Self. These concepts are of inestimable value in analyzing the potential
for occupational crisis. It is the Merger Self that permits temporary fusion with
others through love, identification, or sexual union. If uncontrolled, the Merger
Self can be dysfunctional through fostering dependent attachments and
relationships that preclude autonomy. If the Seeker Self is dominant, the
search for personal achievement may rule out emotional commitment or
involvement with others. What is productive is for neither the Merger Self nor
the Seeker Self to be in sole charge, but for each to balance the other.
Clinical example: Marital crisis of Productivity
George and Dolly Mann were professional musicians in their twenties. They were
employed in an urban orchestra, had been married eight years, and were childless
by choice. The orchestra was often on tour; as a result, the Manns spent
considerable time
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traveling from city to city. One day the intake worker at the community mental
health center in the neighborhood where they lived received a call from Dolly who
sounded excited and desperate. "You have to do something about my husband, I
can't stand living with him another minute. I must talk to someone before I kill
myself." The intake worker succeeded in calming Dolly and obtained enough
information to make an appointment for Mr. and Mrs. Mann to be seen that evening.
Both appeared promptly to keep the appointment.
During the assessment interview, it was disclosed that the orchestra had terminated
Dolly about two months earlier. She had become less and less able to play her violin
because of an arthritic problem in her hands. When the orchestra manager informed
her that she was not employable, Dolly was filled with despair. She accused her
husband of being indifferent to her predicament and reported that life with him was
intolerable. She said that he constantly found fault with her and yelled at her that
she should find another job right away. In turn, George accused his wife of
screaming at him, throwing things, and physically attacking him.
As the interview progressed, it was obvious that the couple agreed on only one
detail-that Dolly had lost her job. They bickered over every fact, each contradicting
and interrupting the other. The mental health worker realized that husband and wife
were in a period of severe stress, and tried to review the chronology of their
relationship in order to assess their customary interaction patterns. This approach
elicited more arguments and grievances. Each reported that the other was always
dissatisfied and looking for a fight. There was no indication that they had ever
interacted in any other way, nor that they were distressed by their interactional
pattern until Dolly lost her job. The job loss had produced a crisis, and they wanted
someone to do something immediately to relieve their distress.
The couple agreed to attend five marital sessions with the agreed-upon goal of
helping Dolly calm down and begin looking for some kind of job that she could do in
spite of her physical impairment. In the sessions the couple examined conditions in
which arguments began, and ways in which insults and accusations could be
avoided. Rules were developed for discussing issues calmly and for focusing on the
real cause of their disagreement. Instead of issuing ultimatums, George was
instructed to use the phrase "it seems to me" when trying to explain his viewpoint
to his wife. This simple phrase reduced contention because it gave Dolly an
opportunity to describe how things seemed to her. At the end of the session
contract George stated that there was less fighting at home and that his practice
schedule did not give him time to continue the meetings. Dolly agreed that they
were fighting less and could discontinue sessions even though she still had not
found a job.
A week later Dolly called the clinic requesting to renew the sessions. She had a
sense of unfinished business and wanted to understand her part in maintaining the
conflict in her marriage.
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She wanted to define and modify her own behavior in her relationships with her
husband and other people. With assistance from the mental health worker, Dolly
began to look at her own behavior. While she had observed and criticized her
husband's actions for years, Dolly had spent no time examining her own actions.
She learned that she presented herself in such a way that other people, including
her husband, thought her helpless and barely competent. Due to the arthritis in her
hands, she could not perform as a professional musician. In fact, she could no longer
do needlework, which was a pastime she always enjoyed. Since her husband used
the car, she could not go anywhere during the day. She was afraid that she could no
longer drive alone and must depend on her husband to take her.
Critical Guidelines
The mental health worker did not make suggestions or give specific advice about
how Dolly might solve her problems. That would have prolonged the pattern of
dominance versus dependency that the client said she wanted to change. Instead of
making suggestions that Dolly would probably reject, the mental health worker
helped the client search for alternative behaviors. What had Dolly thought of trying?
What had she done to solve her problems in the past? What had other people done
in circumstances similar to hers? What sounded reasonable to attempt? There were
times in the sessions when Dolly accused the counselor of being uncaring and
indifferent, but within a few months she had figured out how to drive the car herself.
This was her first step in realizing that she tried to get other people, especially her
husband, to help her, and then resented their interference. She recognized that
there were many things she could do by herself. This led to her considering what
she was capable of and what she needed to achieve. Once she made some
decisions, she began to put her plans into effect. She decided to teach music to
children. Although she could no longer play well enough to perform, she was enough
of a musician to give lesson.
During the sessions the counselor explained about family systems and how they
work. As Dolly moved toward independent functioning, the mental health worker
predicted some strong reactions from George, who had learned to deal with his
wife's anger but not her autonomy. This helped prepare Dolly for her husband's
responses to her changed behavior. He was furious when she first suggested he
form a carpool to get to work so that she could have the car three days a week. She
did not retreat and finally he agreed. After some months she told the mental health
worker that the orchestra was going on tour. She would be traveling with her
husband for a time but would continue to teach her pupils on her return. She said
that she still became upset when her husband was angry with her, but instead of
fighting back, she tried to avoid an argument without giving in completely.
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To summarize the outcome, once the immediate situation improved the husband
dropped out of treatment. His wife, who was in more distress, was not satisfied with
minimal results but wanted to change the interactional pattern of her marriage. She
was willing to make changes in her own behavior. Even though her husband resisted
change, his wife's actions led to alterations in the marital system. Inevitably, her
altered behavior influenced the interactional patterns of the couple in ways that the
wife welcomed and the husband came to accept. He found disadvantages as well as
advantages in having a more independent partner, but overall, family functioning
improved.
After the marital crisis had subsided, the mental health counselor determined that
Dolly needed further help. She seemed in control of her feelings, but undoubtedly
she was very distressed at the loss of her career as a performer. She was less selfdestructive in her dealings with her husband, but without additional counseling she
might revert to her old patterns. Although her schedule was irregular, Dolly agreed
to meet with a new therapist several times a month and to take the initiative in
arranging appointments.
Career Choices
Young adults who discover their talent early in life and who have the means
and motivation to develop their talent are indeed fortunate, but they probably
comprise a minority. Some individuals have several gifts at their command and
may have difficulty deciding which gift to develop. A number of physicians, for
example, concentrated on a medical career in their youth only to forsake
medicine for a literary career in midlife. For less gifted persons the search for
some occupation they want to pursue is fruitless. Instead of finding something
they like, many must content themselves with avoiding an occupation they
really abhor.
Pressure on young people to succeed begins early in life. Greenberger and
Steinberg (1986) allude to such pressure in their comment that adults no
longer display the attitude that youth should be a time of protection from
forces that are unnecessarily painful or stressful. Instead, the attitude of adults
now is that youth is a time of preparation. Friedenberg (1987) deplored the
fact that employment open to young people in the United States impoverishes
their development even as it puts some money in the pockets of their jeans. In
the United States there are no apprenticeships except in rare cases. Afterschool and spare-time employment seldom provide adolescents a taste of a
career they might like to pursue. The inadequacy of employment available to
most high school and college students, combined with parental admonition to
''make the most of yourself," renders career decisions very difficult for
conscientious (and not so conscientious) young people.
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was moving to Virginia, would get a job as a legal secretary, and that they should
get married. She spoke in detail about the visit.
The relationship of this couple had been chaotic at best. Katie herself characterized
it as "can't live with him and can't
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live without him." Pete had tended to be dependent on her as well as manipulative
and exploitive. This pattern had continued despite his move south.
On arriving, Katie learned from Pete that he had just begun a casual sexual
relationship with another young woman. Nonetheless, Pete claimed the other
partner needed him as she was recently divorced. He asked Katie to give him time
to work it all out. Katie was very upset but did not want to give him an ultimatum.
She returned home, unsure of what would transpire, to face a heavy workload both
at her job and at college.
The clinician she saw assessed that Katie was conflicted but not suicidal. She
referred Katie to a physician in the college health services program for relief of her
physical symptoms. The psychologist and Katie reviewed her options regarding work
and school pressures. Katie was asked what would happen if she did not graduate
soon. Katie began to realize that although she and her family would be
disappointed, there would be no long-term adverse consequences. Similarly, they
explored Katie's expectations of Pete. In this instance, the clinician did try to
increase Katie's insight about her panicky flight to the romantic lover of her
adolescence. She encouraged Katie to describe what life would be like for her if she
and Pete married. Katie's response was "I'd get bored pretty fast."
Katie gradually revised her implusive plan simply to move to Virginia and work. She
intended to aim for graduating in several weeks. On the last of her follow-up visits,
Katie felt markedly better; her marijuana use had decreased to almost nothing, and
she had graduated on time. Her plans about moving were further revised. She had
acquired a full-time job and would not move to Virginia: "After all, there's more to
life than the beach!" She continued to be undecided about law school but had not
totally rejected that goal.
Although Katie was not sure what path she eventually wanted to follow, she was
sure that graduating from college was her first goal. With the help of a few
professionals, she came to realize that other decisions could be deferred until she
was less conflicted. Katie had learned some significant things about who she was,
and how to use her own thoughts and feelings in making decisions. The
practitioners assured Katie that she could return for counseling in any situation if
she considered it necessary. She also suggested that Katie take the law aptitude
test in the near future. This would not prematurely commit Katie to any single
course of action, but would provide useful data on which to base a later decision.
Critical Guidelines
The practitioner in the college counseling service had known Katie since her
freshman year. She knew that Katie's plans for law school were realistic in terms of
her ability, although her motivation was less clear. The practitioner determined that
Katie was in crisis because she could not reconcile her ambitions for
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law school with her wish for a sustaining relationship with Pete. In effect, this was a
conflict between Katie's seeker self and merger self. Even Pete's questionable
actions did not cause her to break off the relationship with him. Her subsequent
behavior at college placed her at risk for not completing requirements for
graduation. Katie was referred to a physician and psychologist.
Wisely, the practitioner did not urge Katie to make any decision except on the
advisability of finishing her course work and graduating with her class. Although
Katie could not be seen at the college health facility after graduation, the
practitioner assured the girl of her continued interest and of an appropriate referral
in the future. Much of Katie's anxiety was attributable to the uncertainties of life
after graduation and her reluctance to leave the cocoon of the campus for full
membership in the working world
Parenthood Issues
Parenthood may occur before marriage, early in a marriage, or after a short or
prolonged delay. There are advantages and disadvantages to childbearing,
whatever the timing. Couples who must deal with an immediate pregnancy
may have financial and relationship problems, especially if the first pregnancy is
soon followed by a second. Often young husbands are uninvolved with
domesticity or child care because they are struggling to earn a living, or
because they want to go on feeling free and unburdened. Developmentally,
new parents who are very young have a hard time moving from adolescence
into adulthood. When parents have barely entered adulthood they face the
task of resolving their identity as adults along with forging a new identity as
parents.
Partridge (1988) saw the psychological birth of a parent as an emotional and
cognitive process, not unlike a child's gradual development of identity. Benedek
(1970) wrote that a mother's sense of herself as a parent is built upon her
successes and failures in feeding and nurturing her child. Fathers and mothers
draw upon their memories of their own childhood, and how their own parents
defined and portrayed working images of parenting (Partridge, 1988). Jordon
(1990) described in very sympathetic language the struggle of expectant and
new fathers for "relevance."
Brunnquell et al. (1981) emphasized the essential attributes of self-awareness,
insight, and self-understanding in developing positive parental identity. He
found that mothers least likely to neglect or abuse their children were capable
of the following behaviors:
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a blow to their own parents, who had looked forward to grandparenthood. The
parents' comments and questions annoy the couple, especially if one partner is
more determined than the other not to have children. Having decided to be
childless, a couple may need help in constructing a life style that compensates
for the lack of children. Many childless couples invest
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Some women, of course, find personal fulfillment in jobs and careers. However,
there are vast numbers of women who hold jobs out of economic necessity,
who reluctantly leave infants and children in the hands of secondary
caretakers, and who would prefer to be at home with their children, especially
during the early years. Childcare arrangements are
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often unreliable and working mothers are often uneasy about the welfare and
the whereabouts of their children while they are at work.
The social and geographic mobility of recent decades has deprived families of
the assistance the extended family once offered. In the absence of helpful
relatives, husbands are pushed into performing untraditional tasks. While
economic pressures keep many women in the workforce, the scarcest
commodity in dual income families is discretionary time.
The responsibility for nurturing children and for maintaining a wholesome
environment for the family is still left to mother, although men with working
wives are involved to varying degrees. It is little wonder that the two-income
family finds itself torn between home and work, trying to find the time and
energy to do justice to both. In single-parent households the pressures are
even greater, and resources of time and money are far less.
Although social disapproval has lessened, criticism of working mothers has not
disappeared. Brazelton (1986) advised new mothers not to leave a child under
four months old with a secondary caretaker because earlier separation from
mother may impede optimal attachment between mother and child. To protect
herself from the pain of leaving her baby, a mother may adopt distancing
defenses. According to Brazelton (1986, p.22), "The younger the child and the
more inexperienced the mother, the stronger and more likely are these
defenses. They are correlated with the earliness that mother returns to work."
The defenses outlined by Brazelton include the following:
Denial. A mother is likely to deny that her leaving may have consequences for
the child. She may ignore signals to the contrary in herself or the child. Thus,
denial may impair the mother's ability to make wise decisions.
Projection. Responsibility for both good and bad childcare issues will be
projected to the substitute caretakers, thus allowing mothers to avoid
involvement.
Detachment. Sidestepping responsibility and discounting her strong feelings of
attachment to the child eases the painful reactions to separation.
The large number of women employed outside the home has generated
research into the dynamics of dual-income families, especially where there are
children in the home. During the 1980s, women consistently performed more
homemaking and childcare tasks than their male partners (Pleck, 1985;
Kimball, 1988). When males did participate, their contributions were more in
the area of childcare than in housework. Fish et al. (1992) reported that men
were more likely to be involved with childcare if the firstborn is a boy. This may
be because fathers are more comfortable with the physical and social needs of
a boy, or because mothers encourage more father involvement in the care of a
son.
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In one study, Coverman and Sheley (1986) reported that husbands of working
wives spent no more than twenty-six minutes per day in childcare. Hall (1992)
found that couples redefined roles after the birth of their first child.
Redefinition for women meant taking on multiple roles and experiencing role
strain. For men redefinition produced less role strain because they monitored
priorities. In general, women in dual-income marriages assume more
responsibility for maintaining relationships within the marriage, and outside the
marriage with relatives, friends, and religious affiliations. Household tasks are
divided along gender lines, with men more involved in car and house repair
and maintenance, and women more involved in cooking, laundry, sewing, and
grocery shopping. Major time-consuming chores such as preparing meals,
caring for sick children, and maintaining a liaison with children's schools were
delegated to mother. Evidently the perception of equality is more crucial in
dual-income families than is the real division of labor (Fish et al., 1992). The
uneven division of family responsibility may be reinforced by the greater
earnings of men. As the primary source of family income, the employment of
the male receives more respect than the less remunerative job of female
partner (Pruett, 1987).
Clinical Example: Crisis in a Dual-Career Marriage
Veronica and Archie were high school sweethearts who entered the same university,
studied together, lived together, and were married during their senior year. Both
were outstanding students whose grade averages were rarely more than one-half
point apart. Shortly before graduation, both were admitted to the same medical
school, and as a minority group member Veronica received a generous grant. Archie
negotiated a student loan and was partially subsidized by his parents. The couple
had planned to begin medical school together, but Veronica became pregnant early
in the summer. Unwilling to undergo an abortion, she requested and received
permission to defer her entry until the following year. Archie entered medical school
in September as originally planned.
During the time that Veronica stayed at home to care for her baby daughter, she
often felt envious of Archie's progress, but she told herself that her turn would come
soon. The following fall when her baby was six months old, Veronica eagerly began
her medical studies. Archie by that time was a second-year student who had already
proved his ability. A friend of Veronica's who was a registered nurse, divorced, and
the mother of two preschoolers lived in an adjoining apartment and agreed to care
for the baby during the day. The nurse was capable and attentive to children, so
Veronica envisioned no problems in that area.
When Veronica functioned as a full-time housewife and mother, she did all the
housework in addition to caring for the
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baby. Although she and Archie had not discussed in detail the mechanics of daily
living after she returned to school, Veronica had assumed that she and Archie would
revert to the task sharing of their undergraduate years. This was not exactly what
Archie had in mind. While Veronica was at home, Archie had established the habit of
studying with classmates and was reluctant to discontinue this practice. When
talking to Veronica he glossed over the difficulties of the first year in medical school,
assuring her that she had nothing to worry about and that the requirements of the
second year were more difficult. Although Archie agreed to share shopping and
cooking chores, he made no contribution to the evening care of the baby,
concentrating on his studies as Veronica hurried to feed the baby in order to get to
her own academic work. Sensing Veronica's impatience, the baby became
increasingly fretful. The baby's fretfulness in turn annoyed Archie, who criticized
Veronica and the baby and found excuses to study at the library or with a friend.
Tied to the apartment every evening, Veronica cared for her cranky baby.
Frequently she did not get to her books until 10 o'clock or later. Not long afterwards
Archie would come home with his own assignments mastered and promptly go to
bed for the night. By studying until 2 or 3 A.M., Veronica barely managed to keep up
with her studies. She worried about the baby and realized she was robotlike in her
interactions with the child. Discussions with Archie about her predicament
degenerated into shouting matches. On one occasion Veronica accused him of
deliberately making her pregnant so he could be the superachiever of the family. He
responded by saying it wouldn't help them if they both flunked out of school. After
several quarrels and barely passing her midterm exams, Veronica issued an
ultimatum. Either both of them would visit a marriage counselor, or Veronica would
leave Archie and move in with the nurse who looked after the baby during the day.
Both partners were equally committed to their careers, but only the wife was
accustomed to performing parenting responsibilities. There was some sharing of
household tasks, but childcare was not integrated into the pattern of family
obligations. During pregnancy the wife had deferred her career ambitions, but the
choice was not carefully discussed at the time. The wife made the decision by
default, and the husband failed to realize that for his wife the decision was a
genuine sacrifice that deserved recognition and future guarantees from him.
Although the couple had adhered to a standing pattern of egalitarianism in their
relationship, parenthood had shifted the balance in favor of the husband.
Inadvertently, the husband had placed his wife in the position of sacrificing too
much for too long. Preoccupation with his own goals caused him to overlook the
deprivation and embitterment of his wife. Oblivious of the routine demands of
parenthood, the husband willingly accepted financial responsibility for his wife and
child at some future point. Fear of not being able to provide for his family caused
the husband to devote all his attention to his career. His excessive
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attention to his medical school studies was perceived by his wife as selfish but was
more attributable to his wish to provide financial security. What he failed to realize
was that his wife wanted to be a provider also and resented being relegated to the
role of wife and mother instead of equal partner.
Critical Guidelines
Marital counseling focused on improving communication between partners. Even
though Veronica and Archie knew each other as lovers, students, and spouses, their
parenting roles were new. Veronica expected Archie to know intuitively when she
needed help, just as he expected her to know intuitively that he appreciated her
sacrifice in postponing medical school. Each needed to learn to express his or her
own feelings, to ask directly, to acknowledge openly, and to compromise. The path
they had chosen for themselves was difficult even without the added responsibility
of a baby. The wife was unwilling to give up her dream of a medical career and
unaware that her husband had reshaped the dream without her concurrence. What
remained was for these two intelligent young people to begin a protracted process
of negotiation and to turn their attention to rebuilding a relationship that had
already proved its importance to them. With equitable and flexible role sharing the
primary goal, the following issues were addressed:
1. Adequate support systems for childcare and housework needed to be arranged.
Evening help was necessary so that Veronica could relax for an hour or so with her
child before beginning her studies. This period of relaxation should involve Archie as
well as his wife and child.
2. Archie needed to resume sharing his study time with his wife rather than with his
classmates. With both partners entering the same profession, they spoke a common
language. If Archie used his newly acquired knowledge to help his wife through the
first competitive year of medical school, their relationship would be strengthened
and their former pride in each other restored.
3. Both partners had a threefold obligation: to each other, to their child, and to their
careers. A delicate balance could be maintained only if role enactment in all three
areas included both partners.
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age, gender, economic status, and chosen life style. When the overall
appearance of a person in crisis differs from customary patterns, the difference
may be an indication of the extent of the crisis. People in crisis who are able to
conform, or attempt to conform, to customary standards may be exhibiting a
desire for acceptance by others, desire for relief, and willingness to participate.
The debilitating effects of the crisis have not erased the individual's concern for
how she appears to others. In addition to external details, the individual's
posture, movements, facial expressions, and emotional expressiveness must be
observed. Gait and posture can be extremely revealing, as Dixon (1979) noted
Gait and posture are fairly easy to interpret. For example, a slow, methodical gait
can show depression, fatigue, discouragement, lack of interest. On the other hand, a
rapid gait could represent anxiety, fear, or agitation. Posture, like gait, very often
expresses a specific mood or affect, from the person who slumps in a chair to one
who perches on the edge of the seat. Also, posture may represent changes in affect
during the course of the interview. An example is the client who rocks continuously
in the chair until the therapist says something that is significant, and then stops.
Posture can also indicate boredom and disinterest (p. 73).
Questioning and exploring are other powerful tools available to the counselor.
Besides gathering information, questioning helps clarify an individual's
confusion and misperceptions. Exploring consists of pursuing a subject in
greater depth, and is sometimes used to facilitate emotional catharsis.
Exploring should be titrated to the individual's tolerance levels. This is a
therapeutic tool whose use demands some expertise. It is not the same as
probing, which is an investigative technique that lacks the empathic sensitivity
that should accompany exploration. Probing is concerned with obtaining
information, not with the sharing of emotions.
Techniques of crisis counseling usually have one or more of the following
objectives. These are: (1) to provide psychological support, (2) to promote
cognitive correction, and (3) to alter relationships between the individual and
the environment. Four types of intervention techniques are available to the
counselor, depending on the characteristics of the individual and the crisis
situation: confrontation, persuasion, suggestion, and directive advice.
Confrontation is indicated when an individual steadfastly resists the reality of a
situation or problem. It should be used judiciously, beginning with mild,
nonthreatening admonitions. For example, the counselor might remind the
individual, ''Since you must vacate your apartment in two weeks, perhaps you
should begin to look for another place." Mild confrontation may be sufficient,
but stronger measures may be needed, such as, "I know you want to keep
your family together, but this won't
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happen if you are homeless. What can be done to help you find another place
to live?"
Persuasion can be an effective technique for people in crisis who cannot
choose between several courses of action. A man contemplating a career
change should make his own decision on the matter without being directly
guided by a counselor. At most, the pros and cons of any decision should be
presented, and the man should draw his own conclusions. This is not true
when one course of action is clearly in the best interest of the individual.
Persuading a sexually promiscuous person to be tested for human
immunodeficiency virus (HIV) or urging vocational testing for a person
considering a career change are certainly appropriate.
In resorting to persuasion, a counselor may be rather forceful. Suggestion is a
mild, tentative form of persuasion that leaves the individual free to follow or
ignore the suggestion. Choosing suggestion over persuasion is based on the
personality structure of the individual. Persuasion may evoke resistance in
many individuals who may be willing to accept suggestions, after some
reflection. A good rule for counselors is to begin with suggestion and move to
persuasion only if the situation warrants it.
When an individual is unresponsive to less direct techniques, directive advice
may be given on rare occasions. A counselor may utilize suggestion or even
persuasion to recommend a desirable course of action; only when an individual
is at risk of endangering the self or others should direct advice be given. A
counselor may advise a family to hospitalize a suicidal member or tell a
frightened woman to get a protection order, but such prescriptions should be
given with care. The person in crisis may seem so helpless that the counselor is
tempted to take charge. However, people who are assisted in drawing their
own conclusions and making their own decisions tend to be more satisfied with
the results.
Environmental Alterations
Environmental alteration may be defined as altering the nature of the
environment or removing an individual from a harmful environment. Helping a
harried mother arrange part-time day care for three preschoolers or
recommending an overdue vacation for dual-income families are forms of
environmental modification. Hospitalization or foster care placement are more
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sizes their value but does not imply that their effective use is limited to young
adults. Entry into adulthood presupposes some progress in cognitive and moral
development, and young adults usually have the capacity to respond to the
interventions described in this chapter, even during the disequilibrium of crisis.
Summary
Adulthood may be divided into three stages: early, middle, and late; this
chapter dealt with typical crises of the first two stages. Disequilibrium arising in
early adulthood is likely to be concerned with options and decisions. Crises of
productivity, crises of commitment, and crises of decision were selected to
illustrate common disruptions that occur in adult life.
Crises of productivity emerge from conditions encountered in jobs or careers.
This type of crisis may affect individual workers or it may affect the whole
family. Lack of meaningful work and dissatisfaction with occupational
advancement may cause psychological distress or contribute to
psychophysiological dysfunction in workers.
Professional counseling around abortion should not be persuasive or coercive,
but should be devoted to reducing emotionality and helping women make
decisions compatible with their lifestyles and value systems. Once the decision
is made, counseling should be directed toward helping women live with the
choice they have made. Women are most receptive to contraceptive advice just
after delivery or abortion, so professional counseling should not be prematurely
terminated before that point.
Younger women dealing with unplanned pregnancy are more responsive to
influence from others. Pregnant women who undergo amniocentesis in order to
determine fetal abnormality generally regard abortion as preferable to bearing
a child with a congenital disability.
The same anticipatory guidance is useful in dual-career families in which job
aspirations of the wife may be construed as problems by husbands and
children. In dual-career marriages the scarcest commodity is time. With time at
a premium, couples may disengage or one partner may expect the other to
sacrifice personal hopes and dreams.
Parenthood brings an infinite potential for stress, regardless of family structure.
Single parents become overwhelmed with their responsibilities as wage earners
and as the primary nurturers of children. In intact families where both mother
and father work outside the home, problems may be different but no less
intense. Some of the problems that young adults face can be solved on a
personal or interactional level. Other problems, such as the national need for
safe and effective childcare, must be solved through social, political, or
legislative channels.
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The chapter concluded with a discussion of specific strategies that are useful in
counseling adults. The strategies may be adopted in counseling midlife and
older adults as well as those in earlier adult life.
References
Benedek, T. "The Family as a Psychological Field." In Parenthood: Its
Psychology and Psychopathology, edited by E.J. Anthony and T. Benedek.
Boston: Little Brown, 1970.
Brazelton, T. "Issues for Working Parents." American Journal of
Orthopsychiatry 56(1986): 14-25.
Brunnquell, D., L. Crichton, and B. Egeland. "Maternal Personality and Attitude
and Disturbances of Childrearing." American Journal of Orthopsychiatry
51(1981): 680-691.
Chess, S. "Women's Work." Readings 1(1986): 23-25.
Coverman, S., and J.F. Sheley. "Changes in Men's Housework and Childcare."
Journal of Marriage and the Family 48(1986): 413-422.
Erikson, E. Childhood and Society. New York: Norton, 1963.
___. Identity, Youth, and Crisis. New York: Norton, 1968.
Ersek, M. "Examining the Process and Dilemmas of Reality Negotiation." Image
24(1992): 19-25.
Fish, L.S., R.S. New, and N.J. VanCleave, "Shared Parenting in Dual Income
Families." American Journal of Orthopsychiatry 62(1992): 83-92.
Freud, A. The Ego and Mechanisms of Defense. London: Hogarth, 1948.
Friedenberg, E.Z. "Extracurricular Activities." Readings 2(1987): 4-7.
GAP Report no. 126 (Group for Advancement of Psychiatry). New York:
Brunner/Mazel, 1989.
Gerson, K. Hard Choices: How Women Decide About Work, Career, and
Motherhood. Berkeley, California: University of California Press, 1985.
Goleman, D. "In His Own Old Age Erikson Expands His View of Life." The New
York Times, June 14, 1988 ppC-1, 14.
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8
Adults in Crisis: The Middle Years
People are always blaming their circumstances for what they are. I don't believe in
circumstances. The people who get on in this world are the people who get up and look
for the circumstances they want, and if they can't find them, make them.
George Bernard Shaw
Crises in the form of new decisions, new commitments, and new circumstances
continue throughout adulthood. The traditional family life cycle, characterized
by an early phase of expansion as children enter the family, and a later phase
of contraction as they leave, is not typical of all families. Instead, many
individuals experience successive stages of estrangement, separation, divorce,
single parenting or co-parenting, remarriage, and stepparenting. Each of these
transitional stages is likely to be a period of instability for adults and for the
children who are involved. Figure 8-1 shows a model of marriage, divorce, and
remarriage that is common today.
Marriages are complex relationships and failed marriages are not always
marked by formal separation or divorce. However, divorce is an open
acknowledgement that a marriage has failed. It represents drastic change that
affects everyone involved-parents, children, and extended family members.
Even under the best conditions, divorce involves a difficult legal proceeding.
Although grounds for divorce vary from state to state, agreement must be
reached about property, alimony, child support, and custody. Current
estimates indicate that one out of every two marriages is likely to end in
divorce (Brody, 1992).
Marriages end for many reasons. Couples may not know each other well when
they marry, even when they have been living together for some time. Some
have not separated completely from their families of origin and hope that they
will resolve separation and identity issues merely by marrying. Marital partners
mature and grow at different rates. One may develop socially and intellectually
after marriage, while the
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Figure 8-1
Life Cycle Model of Marriage, Divorce, and Remarriage
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Effects on Children
Considerable research has dealt with examining the effects of divorce on
children in various developmental stages, such as early childhood, adolescence,
and young adulthood (Hetherington et al., 1985; Aro & Palosaari, 1992). Other
research has concentrated on gender differences in the reactions of offspring
to parental divorce (Kalter, 1989; Southworth & Schwarz, 1987; Zaslow,
1988). In both kinds of investigation, findings tend to be inconclusive and
discrepant. In studying reactions of offspring to parental divorce, little
attention was paid to the family structure existing after divorce. For example,
children might be living with a single-parent mother or a remarried mother. In
other instances, children might be living with a single-parent father, a
remarried father, or with a stepfather rather than a biological father. In
support of this contention, Zaslow (1988) made the following predictions.
In studies that deal with children living only with the mother after divorce,
findings will indicate more adverse effects for sons.
In studies that deal with children living only with father after divorce, findings
will indicate more adverse effects for daughters.
In studies that deal with children living with mother and stepfather, findings
will indicate more adverse outcomes for daughters.
In studies that do not control for custody and/or remarriage, findings will
indicate no difference in outcomes for sons compared with daughters.
No exact figures are available nationally for postdivorce patterns of custody,
but census data indicate that nine out of ten children in single-parent families
reside with their mother. Furstenberg et al. (1983) warned that the immediate
postdivorce family structure is not stable and that children of divorced parents
usually experience remarriage, and sometimes a dissolved remarriage. Some 57
percent of white children and 13 percent of black children entered stepparent
families within five years of their biological parents' divorce. Moreover, 37
percent of the children in stepparent families again experienced disruption
when the subsequent marriage failed. Thus, the recovery of offspring from the
effects of parental divorce may be complicated by remarriage and by failure of
the remarriage.
Another factor in remarriage of women is the economic consequences of
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averaging 10.6 years, as opposed to 1.8 years for white women. After divorce
black women are less likely to remarry. Demographic differences by race raise
questions as to the effects of divorce, custody, and stepparenting in black
families where the pattern of single-parent mothers is more prevalent (Zaslow,
1988). Across the board, father custody and frequent visitation after divorce
are uncommon. Zaslow reported that the Foundation for Child Development
Study found that noncustodial parents rarely saw their children after divorce.
Only one out of three children living with divorced mothers saw their "outside"
fathers monthly; after two years, there was a marked increase in the number
of outside fathers who had no contact with their children.
Contemporary research views divorce not as a single event, but as a series of
changes and reorganizations that are stressful for all participants, regardless of
age, race, gender, or role (Hetherington & Furstenberg, 1989). Based on a
ten-year retrospective study, Wallerstein and Blakesley (1989) emphasized the
profound effect of parental divorce in shaping the psychological and social
experiences of the offspring as young adults. They asserted that the prevailing
view in American society minimizes the trauma of parental divorce on children.
Loyalty Issues
Despite their anger, confusion, and ambivalence, children may continue to
harbor loving, loyal feelings for both parents for many years after the divorce.
The heavy emotional burden these children carry places them under
considerable stress beyond the usual developmental issues. Wallerstein (1983)
presented six psychological tasks the postdivorce child faces, in addition to the
usual tasks of growing up.
1. To acknowledge the reality of the marital rupture.
2. To disengage from parental conflict and resume customary pursuits.
3. To resolve the loss of the family as it was.
4. To work through feelings of anger and self-blame.
5. To accept the reality and permanence of the divorce.
6. To regain realistic hope concerning relationships.
These are very formidable tasks; years may have to elapse before they are
even partially accomplished. Because failure to accomplish any or all of them
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by intense emotions of sadness and rage. All of the children in the study had
completed task one by the end of the first year of the parents' separation.
Task two: Disengaging from parental conflict and resuming customary pursuits.
The child's anxiety and sadness about the parental separation needs to be put
aside, but this is very difficult to accomplish since the home atmosphere may
be highly chaotic, and the child may feel too unhappy and worried to invest
much emotional energy outside the home. School work usually suffers, and
commitments to extracurricular activities seem to wane. Some pain was eased
in families where the siblings could be supportive of each other. By one to oneand-a-half years after the parental separation, most children in the study had
reinvested in school and outside friendships.
Task three: Resolving the loss. Resolving the loss is perhaps the most difficult
of the tasks. The nucleus of this charge is that the child must recover from his
deep feelings of rejection and fears about whether he is lovable. All children
feel rejected when a parent leaves. Frequent communication with the departed
parent and responsible, consistent contact between the child and the departed
parent help to dispel the child's fears.
Task four: Resolving anger and self-blame. Resolving children's anger and selfblame following parental divorce takes years. The experience of intense anger
that parental divorce generates often goes hand in hand with school truancy
and failure, and delinquent acting out behavior in adolescents. Relinquishing
the anger can pave the way for forgiveness, and only then is the young person
able to get rid of the feeling of helplessness and experience some sense of
relief.
Task five: Accepting the permanence of the divorce. The fantasy that the
divorced will remarry is prevalent among many children. This is especially true
for children who were quite young when the parental divorce took place. Older
children more easily give up this reconciliation wish.
Task six: Achieving realistic hope regarding relationships. This is the task that
integrates all the coping abilities of the person who struggles with pain and
fears about a parental divorce. Many young adults of divorced parents are
afraid of intimate relationships and marriage for fear of failure. The core
question of their ability to love and be loved, and to trust another person must
be resolved. These young adults must find ways to establish and maintain their
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divorce law, legislative changes have been proposed that address the
unfairness of the present system and deal specifically with its deficiencies.
Wallerstein (1986) has described the condition of many divorced women as
follows.
Most experienced a quality of life severely deteriorated from that which they
enjoyed during the marriage. Their emotional lives had become more constricted.
Their loneliness was painful and debilitating despite work and church and
community involvement. Those who still had a child at home were concerned about
burdening that child with their own needs for love and companionship. The
impending separation of mother and child was dreaded by parents and concerned
youngsters alike (p. 12).
It is not only young children and adolescents who react strongly to parental
divorce. Some adult children are devastated by the breakup of their parents'
marriage after a union of twenty-five years or more. This may be especially true
if the adult children have always idealized their
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the marriage. If the partners can manage this, they may avoid the repetition of
the same mistakes in a second marriage.
The recovery period families undergo following divorce may be protracted.
There are some offspring who never fully recover from the pain of parental
divorce and dissolution of their original family. Initially, the post-divorce period
is a time of shock and denial for the children and one
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Divorce affects the whole interpersonal world of the couple, their children, their
friends, and families of origin. Even when the decision to divorce is mutual,
there is an abiding sense of failure. Relatives who have become fond of a
daughter-in-law or son-in-law are conflicted; many divorced persons lose not
only the partner, but significant others as well. There is some similarity
between divorce and the death of a loved one, except that there are no
accepted rituals to help divorced people inter their
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marriage. For the divorced, the dignified finality of death is not available,
because they must continue to interact with former partners during and after
legal proceedings, especially if children are involved. This is unfortunate
because any divorce gives rise to the acute separation anxiety that irrevocable
loss evokes.
There are three possible types of custody arrangements: joint custody, single
custody, and split custody, none of which represents an ideal. In joint custody,
children share their time between parents, and both parents continue to be
involved in relevant decisions about the children. Under single-custody
arrangements, one parent has major responsibility for the children, and the
noncustodial parent has visitation rights and perhaps financial obligations. In
split-custody decisions, some of the children become the responsibility of one
parent, and the other children are consigned to the care of the other parent.
In the past, the inclination of the courts was to favor the mother in custody
decisions, but joint custody is becoming more common. A child's wish to live
with a preferred parent is considered in custody hearings but may not be a
deciding factor. The older the child, the more likely the court is to be
influenced by the child's preference, since adolescents may react to
unwelcome court decisions by running away. Custody decisions are not
irrevocable but may be challenged and changed in some circumstances. If the
custodial parent systematically influences a child against the noncustodial
parent or does not respect visitation rights of the noncustodial parent, court
decisions generally take the form of warnings and orders to desist. If the
custodial parent can be proved guilty of abuse or neglect, or is certifiably
incompetent, the court is likely to revoke the original custody decision.
Joint Custody
If joint custody is to work, there must be a shared willingness on the part of
divorced parents to cooperate for the benefit of the children. Elkin (1987)
described joint custody as an arrangement that equalizes the power, authority,
and responsibilities of parenting. Several advantages of joint custody come
immediately to mind. The children feel less abandoned and are comforted by
knowing that both parents will continue to be involved in their care. The
parents enjoy the luxury of personal time and relief from twenty-four hour
childcare. At the same time, parents making joint-custody arrangements must
be capable of the following:
Parents must have the capacity to separate their marital roles from their
parental roles.
Parents must be committed to the joint-custody arrangement and refrain from
sabotaging it.
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Parents must give the children's needs priority over their own needs.
Parents must engage in effective, problem-solving communication and must be
able to negotiate differences.
Elkin contended that in cases of divorce, fathers have been placed in an
inferior role with little authority and no responsibility except for child support.
Joint custody permits fathers to remain important to the development of their
children and to demonstrate their concerned caring to the children. However,
he conceded that joint custody arrangements are not recommended when
either parent has a record of addiction or substance abuse, or for families
where neglect, violence, abuse, or psychopathology has been present. When
the question of custody requires adjudication, the effect on children is likely to
be severe. However, with divorced mothers working outside the home and
fathers willing to discharge co-parenting obligations, more divorced partners
are choosing to share custody.
Research on joint custody has revealed a new family structure called a
binuclear family system. This new structure is the result of realignment of
nuclear families in which the commitment of both parents to their children
continues after divorce. In a study of urban divorced families, Ahrons (1981)
found that fathers sharing joint custody were less depressed and more satisfied
in their relationships with their children than fathers who did not share
custody. They had a commitment to their children that transcended the issues
of divorce. While recognizing their incompatibility, the parents valued each
other on behalf of the children, and believed that having two parents who
shared custody was better for the children than being reared by one parent.
Ahron's longitudinal study produced interesting data, as shown.
Parental commitment to joint custody produced unusual living arrangements.
Some children lived one year with one parent and the following year with the
other parent. Others alternated between maternal and paternal households
every three months, every two weeks, every half week, and every other day.
Whenever possible, and in all instances in which changeover was frequent, the
children attended the same school or day care program regardless of which
household they shared. Financial arrangements between the parents were
diverse, but in all cases the fathers met their financial obligations regularly.
In general, adults favored joint-custody arrangements. The mothers enjoyed
being able to pursue activities outside the home without having to be full-time
parents. Fathers welcomed continued involvement with their children even
after they remarried. Joint custody seemed to reduce any role strain on one
parent and made both parents more free to establish new relationships. From
the parental viewpoint, joint custody alleviated their own feelings of guilt,
lessened the deprivation of the children, and distributed the responsibilities of
childrearing.
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Joint custody apparently was less successful for the children, even though they
seemed to appreciate efforts their parents made to implement the
arrangement. For the most part, the children were able to adapt to two
residences, although some of the traveling and household changes were
confusing, especially to children between four and five years old. Older children
between seven and nine years voiced frustration for having to remember so
many different things, such as where the utensils were kept in each household.
Continuity of school life and maintaining customary friendships were important,
especially for adolescents, who complained that changes of residences
hampered peer relationships for them.
Children participating in joint-custody arrangements were preoccupied with the
feelings and sensitivities of their parents. If one parent seemed lonely or was
less secure financially than the other parent, the children worried about this
parent. Despite their awareness of the efforts of their parents, the children
experienced periods of sadness and entertained thoughts of being united as a
family. Although the opportunity to witness cooperative interaction between
their parents reassured the children, it also encouraged fantasies of
reconciliation that persisted years after the divorce. Although the children
seemed able to deal with the practicalities of living in two homes, certain
aspects of their existence proved difficult. For the most part, joint custody
seemed to be less burdensome for parents than for the children, who seemed
to suffer some disadvantage. With joint custody a current alternative to the
customary practice of awarding legal custody to one parent and visitation
rights to the other, there is need for careful preparation and further
investigation before divorced parents routinely embark on this complicated
course.
Even though the parents may have not yet worked out the dimensions of their
new relationship, it is inadvisable for the children to remain isolated from the
noncustodial parent. Sustained contact with the noncustodial parent reduces a
child's fears of abandonment, counteracts the tendencies of single parents to
construct a closed family system, and fosters a semblance of continuity
between the old family and the new.
Children living with one parent lack the opportunity to witness day-to-day
transactions between men and women, and tend to become possessive toward
the single parent. Losing one parent intensifies the child's ties to the custodial
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thinks of himself as the mother's "man of the house" or the pal of father is also
likely to see potential stepparents as intruders. Maintaining distinct intrafamily
boundaries is one method of avoiding undue resentment when the single
parent considers remarriage.
The Single Parent
Unless a mother is demonstrably unfit or incompetent, it is she who is usually
awarded custody of the children. However, many fathers make valiant efforts
to remain involved in the lives of their children, even after they become the
outside parent. For either custodial parent, the burdens of single parenthood
are great. Loneliness, hurt, and the struggle to put one's life back together
have to be faced, as well as the ever-present financial problems. Many singleparent mothers are so overburdened that their emotional availability to the
children is limited for many months past divorce. Visitation poses problems
also, particularly if the separated/divorced parents have different sets of values
and rules. In their own upset emotional state, children do not know what to
think or believe and are at high risk of developing serious emotional and
behavioral problems.
A divorced mother may need to supplement support payments, but she may be
inadequately prepared to enter the job market. She must either accept a
reduced living standard or find a way to obtain a marketable skill. Should she
take courses or find a job, she will incur the additional childcare expense. A
divorced father who pays child support or alimony has less money for his own
needs. He, too, may be forced to accept a less comfortable standard of living.
Divorced homeowners may have to give up the family residence and move to
less-expensive quarters. Renting in a lower class neighborhood is very different
from owning a home in middle class suburbia. The mother without access to
support payments may have to apply for public assistance. Economic privation
adds to the adjustment problems. The employed single-parent mother has little
or no time for herself and has to be the sole decision maker, the sole
disciplinarian, the sole "everything."
Mothers Without Custody
Much has been written about fathers without custody; less is known about
mothers without custody (Rosenthal & Keshet, 1981). United States Census
Bureau data show that the number of mothers without custody tripled in the
last decade. Greif (1987) noted that these mothers comprise a little known and
misunderstood group, perhaps because of social disapproval toward them.
Greif compared noncustodial mothers who were content with the arrangement
with those who felt guilty and uncomfortable.
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The mothers in the study had lived without their children for about four years.
The children lived with their father rather than with relatives or in institutions.
The income of the mothers, including alimony, was higher than the average
income of women who lived alone and higher than the average income of
single-parent mothers living with their children. Most, but not all, had given up
custody without a court battle. What the study showed clearly was that
mothers without custody are not a monolithic group. There was a clear division
between three types of noncustodial mothers: those who were comfortable
with the role, those who were uncomfortable, and those who had mixed
reactions.
The mothers who expressed contentment were women who admitted some
responsibility for the marital breakup, had a positive relationship with their
children, and had some success in a job or career. The noncustodial mothers
who were dissatisfied with the arrangement had lower self-esteem, poor job
and social skills, and pervasive feelings of failure. They blamed the father for
the marital problems and considered themselves to be victims, especially if they
had lost custody in a court battle. They seemed to have no identity or role
except through motherhood. In contrast, the satisfied noncustodial mothers
had broader interests and skills. Implications for counseling of the unhappy
mothers included the following goals: to mourn and work out their sense of
loss; to improve vocational and social skills, and, if possible, to improve
relationships with their children.
The single father, with or without custody, tends to be an overlooked figure. If
he has custody and is employed, he is likely to hire a housekeeper or ask a
female relative to move in. The divorced father without custody has to adjust
to a different life. He no longer is head of the household and experiences
feelings of anger and sadness about not being able to protect, comfort, or care
for his children. He becomes an income source rather than a provider. A
reduced income due to alimony payments and child support often means a
lower standard of living for him, if he is conscientious about making payments.
Single-parent fathers with custody face a number of hurdles that even
overburdened single-parent mothers do not confront. First, they must integrate
maternal functions into their role as father. Another problem is lack of
sustained support from the community at large. If he is rearing daughters in a
motherless home, unique adjustments must be made. Like single-parent
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friend was friendly and outgoing and was accepted readily by his children. As the
weeks passed, Bob began to enjoy life more and to feel able to sustain a satisfying
relationship with a woman.
Approximately four months after meeting Beth, Bob faced a new problem. His little
boy, Paul, suffered several grand mal seizures in school and was diagnosed as
having idiopathic epilepsy. During this period Beth proved to be a source of
sympathy and support. Therefore, Bob was unprepared for her announcement that
she could no longer see him because she had met a man without children and was
planning to move in with him. Losing Beth was a loss that sent Bob into a state of
disorganization. He could not function either at home or at work. Bob's two children
found their father uncommunicative, absentminded, and lethargic. His little
daughter, Julie, reacted by trying to help out at home. His son reacted by having
seizures more frequently and by worrying about being a ''bad boy."
Bob was struggling to be both mother and father to his children even though the
demands upon him were excessive. His friendship with Beth briefly restored the
confidence that had been shaken by his wife's infidelity. When his son developed a
serious illness. Bob felt overwhelmed and looked to Beth for understanding. She was
supportive for a while, but the multiplicity of Bob's responsibilities frightened her.
Beth's response was to begin a new relationship with a man who had fewer
commitments. Her actions reactivated the grief he felt when his wife left him for
another man. In addition, Bob was having trouble dealing with his son's illness. The
healthy son of whom he was so proud no longer existed. Instead, Bob was left with
a sick boy whom he loved deeply, but whose illness mystified and frightened him. As
a result, he felt overwhelmed. His performance at work suffered until his
sympathetic foreman suggested that Bob accept professional counseling.
Critical Guidelines
The counselor at the mental health center explored with him the history of repeated
losses that Bob had encountered in the previous two years. Bob had handled his
divorce fairly well. For a time he managed to function at work and as a single
parent. However, the illness of his son followed by abandonment from Beth caused
him to feel frightened and alone. Bob was suffering depression that was reactive to
the situational and interpersonal reverses of recent months.
A contract was established in which Bob would meet individually with his counselor
for eight weekly meetings. Following termination Bob agreed to accept referral to a
group composed of single parents who met weekly under the leadership of a
professional counselor. The group goal was to deal with feelings of loneliness and to
discuss problems related to the role of the single parent. During the individual
sessions Bob worked with the counselor in dealing with the following concerns.
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Bob's present work schedule and childcare arrangements were burdensome for him
and for the children. Since his employer was sympathetic, Bob was advised to
request a day/night rotation so the children would not have to be moved from their
beds at midnight.
With minor financial adjustments, Bob found the resources to hire someone to clean
the house and do the laundry every week. This arrangement freed Bob and the
children from housework on Saturdays.
Bob was encouraged to discuss his son's medical problems in detail with the family
physician. Referral to a community health agency was made, and a nurse agreed to
visit occasionally when Bob was at home in order to answer his questions and
explain his son's regimen.
Church affiliation had been important to Bob and the children before the divorce.
This affiliation was seen as an important aspect of their lives, and the counselor
reinforced Bob's idea that he and the children begin attending church again. The
counselor perceived this decision as a means of providing continuity for the children.
Since Bob had already made friends in the local chapter of Parents without Partners,
he was encouraged to resume his interest in this group.
Remarriage
Most divorced men and women eventually contract new marriages and
establish households in which relationships are complex and intricate. A
fallacious idea entertained by divorced adults beginning a new marriage is
belief that a new family will spring effortlessly into existence. Every individual
involved in a stepfamily has already endured a period of acute disequilibrium.
Remarriage means that some turmoil must be undergone again. Among the
problems that must be resolved in remarriage are the following:
The new partner who has chosen to marry a single parent may be reluctant to
accept the children as part of the package.
Former mates may welcome the remarriage of a divorced partner but dislike
the prospect of a stepparent for their children.
Children may not easily discard fantasies that their natural parents will
reconcile, in spite of the remarriage of one parent.
It is unrealistic to expect that "his" children or "her" children will enter a new
family prepared for immediate compromise and harmony. Even when one
spouse is not accompanied by children from a previous marriage, problems of
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remarriage usually begins with the mother in charge of her children because of
their previous experience as a single-parent family. This beginning pattern
gives the mother power to regulate interactions between children and
stepfather and, if continued, does not lead to family integration. A second,
more adaptive, pattern consists of the stepfather initially accepting existing
interactions in the home and respecting prior claims of the mother. Without
making arbitrary changes, the stepfather endeavors to make friends, not rivals,
or the children. Every member of the new family is allowed to become a
participant in developing family rules and norms. This pattern is quite likely to
lead to adaptive family integration. In the third pattern, the new stepfather
attempts to become family disciplinarian, and the mother is divided in her
loyalty to husband and children. A fourth variation consists of the mother
asking the stepfather to function as family disciplinarian, but carrying out only
the decisions of the stepfather that she approves. Thus the mother establishes
a quasi-traditional family in which the father is the ostensible household head
but in which the mother retains actual authority. In the fifth pattern, the
mother relinquishes management of the children to the stepfather, who then
becomes a genuine authority figure. This situation is difficult for the children.
Having lost their natural father through divorce, the children now believe that
their natural mother has been lost through remarriage. Of the five divergent
patterns, only the second contains the promise of adaptive integration of the
stepfamily.
Stepparents
According to the latest available census reports, there were almost five million
children in the United States living in stepfamilies, and this estimate is probably
too low. It does not take into account the children living in households where a
biological parent is living with but is not married to a new partner. Nor does it
include children who have stepsiblings or half siblings living in other
households. Their numbers will increase in the next decade and society will
have to modify its proceedings to suit the special requirements of these
families.
Every stepfamily is comprised of members who have suffered loss of one kind
or another, through death or divorce. Each member may be at a different
stage of becoming reconciled to the loss. This means that when a parent
marries again, reactions can be intense. Stepfamilies not only begin in an
atmosphere different from that surrounding first marriages; they also evolve
differently. Every partner brings to marriage an unwritten contract of their
expectations; in remarriage the contract may be extensive, containing ideas of
childrearing, money management, and task sharing (Visher & Visher, 1989).
Only recently have researchers and other professionals given stepfamilies
attention. Preparatory classes are avail-
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able for pregnant couples, for adopting parents, and for single parents, but
programs for stepfamilies are rare, even though the difficulties these families
face can be severe.
Joint custody is more common than it once was, but mother more often than
father is the custodial parent. Because she has been a single parent before
remarrying, the mother is usually in charge of the children at first. She tends to
continue the practices she has always used. In the new family she acts as the
interpreter and mediator; she explains the stepfather to the children and the
children to the stepfather. This gives the mother considerable power but
impedes family integration. Because he is not the biological parent, the
stepfather initially asks the mother how she wants him to act toward the
children. In response, the mother may suggest that they make no immediate
changes and gradually get used to one another. If the stepfather is willing to
move carefully and makes friends with the children, family integration is
facilitated. In some cases, however, the stepfather, who, after all, is a new
husband, may forcefully assert himself in a manner that makes rivals rather
than friends of the children.
Occasionally, the stepfather behaves harshly toward the children, especially if
they do not make him feel welcome. Unless this behavior is interrupted, the
mother will be torn between the children and her new husband. In this
sequence of events the family becomes disorganized. Everybody makes rules
but no one adheres to them. Family members reach high levels of conflict,
communicating by shouting or by not talking at all. The stepfather and mother
are locked in symmetrical relationships in which both vie for control.
Mothers who are accustomed to the father being the household disciplinarian
may appear to yield control. This is not a genuine gesture if the mother only
enforces rules that she agrees with and sabotages the rest. For example, they
may have agreed on the amounts of the children's allowances or on the chores
they will do, whereupon mother will add to the allowances or excuse the
children from chores without the stepfather's knowledge. Other mothers who
find it hard to handle children may allow the stepfather to be totally in charge.
This may also have adverse effects on stepfather-stepchildren relationships and
make children idealize their intact nuclear family.
Because stepfamilies establish intimate family relationships that are not
biological and have not evolved over the years, sexual boundaries may become
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lives in a state of flux. Even after remarriage, the biological parents must
communicate from time to time about their children. Custody may be awarded
to one or both of the natural parents. Even when one parent has sole custody,
visitation rights mean children must adapt to two different households. The
two households may have very different standards and customs. Differences
become more troublesome when one
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parent derides the other parent and the other household. Children seem able
to fit in better if the biological parents refrain from criticizing each other, and
allow the child and the other parent to define the terms of their relationship, at
least in the early months of remarriage.
The remarriage of a parent is undoubtedly hard on the children. Dad's
relationship with his new wife reveals aspects of his personality with which
children may be unfamiliar. This means that the remarried parent may seem
different. The same is true of mother, whose remarriage causes her to emerge
as a sexual being. At the time of divorce a son's identification with mother may
be reactivated. This is strengthened when mother looks to a son for support. It
is harder for a boy to suppress knowledge of her sexuality as a result of her
remarriage. Based on clinical evidence, it is the relationship between
stepmother and stepdaughter that is most difficult. Bohannon (1984)
explained that daughters during the oedipal romance give up father so as to
identify with mother. Divorce tells the girl that her father is discarding or being
discarded by the mother with whom she identified. When father remarries, the
girl is left with a sense of being mistaken about her parents and of confusion
about the whole identification experience. It is not surprising that many
stepdaughters greet a father's remarriage with doubt verging on suspicion.
Couples contemplating remarriage are already aware that marriage and
parenting are exceedingly complex. If one or both have been divorced, they
have been introduced to failure and dread its recurrence. As a result, many of
these couples arrange for premarital counseling. The overall goal of counseling
is to prepare the couple for remarriage and stepparenting, if there are children.
Counseling sessions can prepare the couple for issues likely to arise. At this
time it may be necessary to review custody and visitation arrangements,
discuss obligations to former mates, and to custodial and noncustodial children.
In stepparent families there may be several children at different developmental
stages. Stepparents need information on what to expect from the children in
terms of their age-related tasks. If stepparents realize that adolescents in all
probability are struggling with separation and independence, they are less
disappointed when adolescents are reluctant to become close to parents or
stepparents.
No new family springs effortlessly into existence, and this is especially true of
remarried families, where every member has already experienced much
turmoil. Among the common problems faced in remarried families are the
following:
The new husband or wife who marries a single parent may be less than eager
to welcome stepchildren as part of the package.
Former mates may accept the remarriage of a former spouse but dislike being
replaced as their children's parent.
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Children are reluctant to give up fantasies that their natural parents will
reconcile, and therefore they see stepparents as obstacles.
Children of divorce feel that adults have let them down. Having lost one parent
through divorce (or death), the children now fear that the remaining parent
will abandon them after remarriage. The most adaptive behavior in stepparent
families begins with the natural parent in charge of the children, provided the
natural parent has functioned as the primary custodial caregiver. The
stepparent initially accepts existing arrangements in the home and respects
the prior authority of the natural parent. Without making immediate changes,
the stepparent endeavors to make friends with the children. Changes ideally
are made through consensus, with all members participating. With minor
adjustments, the same adaptive patterns can be used in remarried families
where some children belong to the mother and some to the father.
Competition is prominent in stepparent families. Stepsiblings are bound to have
problems in living together, and must allow time to become fond of one
another. The stepparent family is more open than other systems, for it must
permit access to natural parents who do not live in the household. The natural
parent outside the home may distrust the interest a stepparent has in the
children and may need to be reassured on this score. At the same time, the
natural parent may fear that the stepparent will usurp the allegiance of the
children. It is necessary for parents in remarried families to remind themselves
and the children that the new family will be the joint creation of parents and
children. Individual and group concerns need to be negotiated, either in
private or with the help of a professional counselor. Discrepant opinions of role
enactment and acceptable behaviors must be resolved for the stepparent
family to remain functional. Difficulties are likely to lie less in resistance to
being part of a new family than to unrealistic expectations that harmony and
accommodation will occur without hard work (Keshet, 1990).
Clinical Example: The Scapegoated Stepchild in a Remarried Family
Bruce and Amanda have been married for five years, and both have been married
before. Living with the couple are Amanda's eight-year-old son. Billy, Bruce's tenyear-old daughter, June, and five-year-old Annie, who was born of the current
marriage. Bruce owns a hardware store with a dozen employees. He is a generous,
paternalistic employer who says proudly that he is like a father to his staff. Amanda
is a few years younger than Bruce. She is a quiet, rather self-effacing woman who is
a fulltime housekeeper and an active worker in her church. She is
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conscientious about everything she does and describes herself as a worrier and a
perfectionist.
Bruce married Amanda when Billy was three years old, and she had been divorced
for six months. Her first husband had walked out when Billy was a baby, saying that
he was too young to settle down yet. At the time of her marriage to Bruce, Amanda
was having trouble dealing with Billy. When Bruce saw the temper tantrums and the
struggles between Billy and his mother, Bruce asked Amanda if she wanted him to
help her control Billy. Amanda welcomed the offer; she realized that she had
indulged Billy after his own father left and she wanted peace restored. However,
Amanda was unprepared for Bruce's idea of discipline. At first he spanked Billy, but
when this had little impact he began beating Billy with a strap. Amanda protested,
but Bruce told her she was too soft with the boy. His methods made sense to him
because he had been beaten the same way by his parents and his grandfather.
The punishments had an effect on Billy. He became quieter and less rebellious,
obeying his stepfather's rules except when he "forgot." Both Amanda and Bruce say
that he forgets the rules pretty often but is improving.
Billy has not seen his natural father in four years. He knows that his father is a
musician who plays in a band and travels from town to town. Billy says that he could
live with his father if he did not travel so much. He likes music and his mother has
told him he can join the school band as soon as he is old enough. When Billy was
six, his stepsister June joined the family when her mother (Bruce's first wife)
remarried. June has not seen her mother since then because the distance is great
and her mother cannot afford to visit. Bruce has not allowed June to visit her mother
because he feels she belongs where she is. June is never beaten because Bruce
does not believe in hitting girls and anyhow "June always knows when to quit."
Amanda enforces most of Bruce's rules but is more permissive. She allows June
considerable latitude and is very indulgent of Annie, "because she is still a baby."
She wonders if Bruce isn't too strict with Billy but doesn't protest much because she
feels that Bruce knows more about raising a boy. Testing at school had shown Billy
to be exceptionally bright, but his school performance is poor. He has few friends
and never brings playmates home from school. The two girls seem happy and welladjusted. Billy is apathetic except about music; he no longer has temper outbursts
but he seems listless and depressed. School personnel suggested counseling for
Billy, or therapy for the family if Billy's academic and emotional status did not
improve. Because school personnel impressed Amanda with the gravity of the
situation, she prevailed upon Bruce to attend sessions with her and Billy. It bothered
her that her son was being labeled a problem child, but she accepted Bruce's
decision that the girls should not participate.
In the family meetings the practitioner observed that Billy was an alert, handsome
little boy who was reserved but eager to please. Although Bruce speaks directly and
firmly to Billy, the
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boy avoids eye contact and answers in a muffled voice. If he is slow in answering
Bruce or the practitioner, Amanda answers for him. Although the two girls were not
present, the practitioner was able to see that one childrearing method was being
used for them and a much harsher one for Billy. Amanda stated that she was
uncomfortable because corporal punishment was inflicted on Billy, but added that he
had been a "handful" and she didn't want him to grow up irresponsible like his
father. She praised Bruce for being a good provider and for his steadiness.
The mother in this remarried family had given her husband total authority over her
son. In the sessions she admitted that before marrying Bruce, she found Billy
uncontrollable. In fact, one of the reasons she married shortly after her divorce was
to give Billy a father. Bruce had behaved in ways that allowed Amanda to become
very close to the girls. The alliances within the household excluded Billy, who was
the scapegoated child. Although Bruce was not introspective, he could acknowledge
that Billy was the only child in the home who was not related to him by blood.
Amanda wields little power in her own right, but she functions as an intermediary
between Bruce and all the children. She protects Billy as much as possible, to the
point of deceiving her husband. Once when Bruce insisted that she beat Billy, she
faked a beating from behind a closed bedroom door. After Bruce has punished Billy,
she provides candy and other treats to comfort him.
The signals from school personnel alarmed both parents. They persuaded Amanda
to intervene more directly on behalf of her son. She knew that Billy was precocious
in many ways and she blamed herself for letting the home situation harm him.
Bruce was not accustomed to being confronted by Amanda and he found himself
consenting when she said firmly that there would be no more beatings of anyone in
the family. Although some progress was made at initial family meetings, the
practitioner urged the parents to bring the two girls as well. Amanda promptly
agreed and Bruce went along with her. She seemed to know that her son had not
been given equal treatment and she was determined to change this.
Critical Guidelines
The family practitioner agreed to meet without the girls only to begin treatment. As
soon as she realized that omitting the girls would again label Billy as the bad child,
she insisted that everyone attend. In this she was joined by Amanda, who
established a therapeutic alliance with the practitioner. Efforts were directed toward
strengthening Amanda's parenting role. Currently Bruce was the primary parent for
Billy, and Amanda was the primary parent for the girls. With encouragement from
the practitioner, Amanda compared her tender parenting of Bruce's daughter with
the stern measures he used on Billy. She accepted much of the responsibility for
putting Bruce in charge of Billy in the early years of the remarriage. What was
needed was shared parental
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functions, not allocation of parenting along gender lines. June and Annie needed
more involvement with their father. Billy needed more involvement with his mother
and a different kind of involvement with his stepfather.
The family changes made Billy feel less isolated. He drew closer to his sisters,
remained wary of his stepfather but felt more protected by his mother. Amanda and
Bruce were encouraged to substitute more rewards and fewer punishments to elicit
positive behavior. Physical punishment of any sort was outlawed because, as
Amanda said, "there has been too much of that already."
Amanda became more active in school events and welcomed any friends that Billy
brought home. Bruce made arrangements for June to visit her mother over summer
vacation. Amanda hesitated to let Billy visit his father because he was so transient.
She wrote to her former husband, telling him that Billy seemed to have inherited his
father's musical talent. She invited Billy's father to visit when he was in the area and
enclosed a letter from the boy. This started a friendship by mail in which Billy wrote
about daily events, and his dad sent souvenirs and postcards from interesting cities.
The turn of events was not wholly welcome to Bruce, but he did not resist too much.
In family meetings, Bruce paid tribute to the kind of wife and mother Amanda was
to all the children. Without anyone saying it directly, Amanda had become a force to
be reckoned with in the household; this benefitted all the children and ultimately
strengthened the remarried relationship.
Adoptive Parents
For various reasons the number of infants available for adoption in the United
States has decreased. This is attributable to dependable contraception, access
to abortion, and social attitudes that encourage a single mother to keep and
raise her child. Because adoptable infants are scarce, the child adopted today
is likely to be well past infancy, and is often of a different race or nationality
from the adoptive parents. Some of these older children have been shunted
from one unsatisfactory placement to another, and may have been victims of
abuse or neglect. Such factors may intensify the problems adoptive parents
and the children they have taken into their home experience.
In the past, heroic efforts were made to match the child with the adoptive
parents, but this is impractical today when couples cross racial and national
boundaries to find an adoptable child. There is a misperception that black
families seldom adopt black children. The truth is that for generations black
families have accepted children in their homes with and without legal adoption.
In addition, children of all races are being raised by grandmothers and other
relatives who must take the place of drug-addicted biological parents. Many
adoptions now result in biracial
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a couple has adopted a child, they remain under surveillance for a time.
Another issue is the decision on how and when to tell a child that he has been
adopted. There is always a fear that a friend or relative may disclose this
information before the parents are ready to do so. There are no set rules on
this matter, since much depends on the child and the situation. Some
authorities believe that most adopted children can be told when they are about
six years old. If the child is older at the time of adoption, or is of a different
race or background, disclosures may have to be made shortly after adoption.
When very young children are told of being adopted, they may become
anxious. Since they lost one set of parents, they wonder if they might lose
another. Some adoptive parents fear that the child will love them less after
learning that they are not the biological parents. If the parents are uncertain of
how and when to proceed, the matter is important enough to discuss with an
expert so that parent-child relationships are not endangered.
Growing numbers of biracial and transnational adoptions mean that counselors
must be sensitive to the problems of parents as well as children in these
families. Participating in support groups, where common problems can be
discussed, can be helpful for parents contemplating the adoption of a child
who is different from themselves. If other children are already present in the
family, they must be carefully prepared for the entry of the new sibling.
Anticipatory planning is indicated on behalf of all family members, actual and
prospective. People who adopt any child embark on a serious mission. In
effect, a stranger joins the family and requires adjustment from everyone. The
adopted parents, the adopted child, and any siblings already in the family need
a gamut of services, including counseling education, practical assistance, and
group support.
A nonthreatening approach for these families is to see troublesome issues as
part of the process of becoming a family. When family members are dissatisfied
with things as they are, they can be reassured by learning that a family is not a
finished product and that family interactions can change for the better. In
most family situations the counselor should consider the marital or parental
dyad as the architects of the family, with all members participating in the
construction of an adaptive and viable family system. This relabeling tactic is
often effective in reducing members' perception of unfairness or injustice in
family operations. It can be adapted for use with stepparent families and with
single-parent families where discouragement and discontent prevail.
Post-Parental Issues
Duvall (1977) was the first theorist to organize and define the tasks of the
family. Duvall categorized eight stages of family development that encompass
the entire life cycle of individual members. During the early
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years of establishing and expanding the family system, the marital couple
either moves toward resolution of divergent loyalties and goals, or remains
conflicted by failure to accomplish resolution. This means that the marital
couple enters the post-parental years with an alliance which has been
weakened or strengthened by past experience. If problem solving has been an
endeavor in which both partners participated, this coping behavior is available
to them. If the couple has not been able to acknowledge differences, or if the
opinions of one partner have always prevailed, the postparental years may be
quite difficult.
Some couples seem able to move tranquilly from active parenting to a life that
remains rich and fulfilling. Others find that the loss of children is traumatic in
terms of self-esteem and marital compatibility. Who, then, are the couples
most likely to require help in adapting to the departure of children from the
home? In order to understand potential problem areas for postparental
couples, it may be helpful to review the developmental tasks of the family.
The developmental tasks of the middle-aged family may be summarized as
follows: (1) rebuilding the marital dyad, (2) maintaining ties with older and
younger generations, (3) providing security for later years, and (4) reaffirming
the values of life that are meaningful. This framework emphasizes the
importance of developing and maintaining interdependent relationships
between the members of the marital partnership. Also regarded as essential
were relationships between the postparental couple and their children, as well
as between the postparental couple and their aged parents. An additional task
was identified for the midlife adult, namely that of adapting self and behavior
to the signals of an accelerated aging process. A couple having difficulty with
any of the foregoing developmental tasks is likely to be at risk. Troubled
couples may need professional intervention of a supportive nature so that the
potential for renewal in the marital relationship becomes an opportunity rather
than a threat.
Counseling Adults
The mature adult lives in a prime-time context. People at this stage of life are
at the height of their powers. At the same time, their lives are complex and
demanding. Usually they are deeply involved with work and family life. Their
interests are rich and varied, and their obligations are wide ranging. Even
though their lives are complicated, they are still young enough to be optimistic
about the future. While these generalizations do not apply to every midlife
adult, they emphasize the fact that most persons in this age group are
embedded in some form of family life. The crises they encounter are likely to
include relationship issues as well as developmental issues.
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limited way that the person in crisis perceives it. By adopting a different, wider
perspective than that of the troubled individual, the counselor can illuminate
the view so that misperceptions are reduced.
Counselors must monitor their own level of anxiety during a therapeutic
session. They should try to analyze what makes them anxious and how to
handle their own anxiety constructively. In crisis sessions, coun-
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selors should limit themselves to working on identified, reachable goals that the
individual is willing to confront. If these goals seem too restrictive, the
counselor may offer the individual some options when the crisis contract has
terminated.
The crises of adults in midlife, whether situational or developmental, invariably
require guidance in accepting reasonable goals. Many mature adults feel that
they have not realized the aspirations of their youth. When they feel
disappointed in themselves or in family members, they may need to be
reminded of the positive achievements in their lives. When they measure
themselves against impossible standards, they may need help in setting
priorities or revising their sense of themselves as inadequate. A man who was
not promoted may need to be reminded of what he has already accomplished
or of what he still has to offer. This approach is not the same as cheerleading if
it is based on reality. Such interventions are a cognitive approach that
counteracts the tendencies of some adults to cling to impossible dreams. At all
times counseling should be considerate of the value system and social context
of the adult, whose energies and abilities may be temporarily depleted by
problems and responsibilities.
Summary
Disequilibrium arising in early adulthood is likely to be concerned with options
and decisions, while disequilibrium of middle adult life is apt to be family
related. Role strain increases and marital satisfaction declines in middle adult
life; therefore, change within this period requires careful planning and
preparation. This is especially true if contemplated change introduces massive
family realignment.
Crises of commitment often result from the realignments that divorce,
remarriage, and stepparenting produce. Several custody options are now
available to divorced parents. Custody decisions favor the mother in most
instances, but joint-custody arrangements are becoming more common.
Although study of the effects of joint custody is not extensive, preliminary data
indicate that the arrangement may be more beneficial for parents than for
children. In single-parent households in which one parent has sole custody
there is danger that family boundaries will be impermeable, and that parents
and children in these households will allow generational boundaries to become
blurred.
The breakup of a marriage has far reaching effects on parents and children;
additionally, the no-fault divorce legislation enacted in the interest of fairness,
has often worked to the disadvantage of women and children. Several
researchers have formulated specific tasks that children and parents must
address after divorce. Unhappily, these are formidable tasks that may or may
not be fully accomplished.
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9
Adults in Crisis: The Later Years
Fortunately psychoanalysis is not the only way to resolve inner conflicts. Life itself
remains a very effective therapist.
Karen Horney
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TABLE 9-1 Personality Patterns of Aging and the Aged
Patterns
Subpatterns
Integrated
Reorganizers. Those who replaced each lost role
personality
with a new role.
Focusers. Those who limited themselves to
satisfying activities only.
Disengagers. Those who willingly and
consciously reduced roles and activities.
Holders on. Those who held on to roles and
Defended
appearance of younger people due to aging
personality
fears.
Constrictors. Those who were extremely fearful
of the aging process.
Passive
Help seekers: Those who sought help and
dependent
support from others.
personality
Apathetic. Those who did not seek help but
withdrew from all contact.
Unintegrated Disorganizers. Those who were maladjusted
personality
and/or displayed gross personality defects.
Source: Adapted from Neugarten (1973), and Kermis (1986).
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person becomes frail and needy, transactions once determined by choice are
now determined by obligation. The middle-aged children of elderly parents find
themselves torn between obligations to their parents, to their maturing
offspring, and to their own partners.
Middle-aged women, in particular, are at the mercy of these demographic
trends, since women traditionally have accepted the role of family caregiver.
This means that many middle-aged women must balance the tasks of
parenting any children still at home, maintaining a full- or part-time job, and
attending to the needs of increasingly infirm parents. Additional stresses occur
as the balance of power shifts in the family system from the aged to the
middle-aged members. The family performs an estimated 80 percent of all care
for elderly people in the United States; as a rule, one primary person usually
performs caregiving responsibilities, even when other assistance is available
(Lawton et al., 1989; Lawton, 1980).
Adaptation to Aging
Developmental tasks have been described as individual adjustments to the
changing self (Erikson, 1963), while adaptational tasks have been described as
adjustments to changing individual and cultural expectations (Clark &
Anderson, 1967). Thus, the process of adaptation requires greater
accommodation between individual capacities and cultural expectations. The
critical adaptational tasks associated with aging have been identified as
follows:
Recognition of aging and its consequent limitations.
Redefinition of physical and social life space.
Substitution of alternative sources of satisfaction.
Readjustment of criteria for self-evaluation.
Reintegration of life's goals and values.
Successful adaptation does not mean that the elderly person must enjoy the
limitations that age brings, but merely that limitations must not be denied.
With advancing age, control over one's social environment is threatened.
Personal space becomes circumscribed as certain activities and roles are no
longer accessible. Searching for alternative interests is part of adaptation, and
individuals who cannot give up total autonomy or accept some dependency fail
to adapt well to aging. Readjustment of criteria for self-evaluation means that
various criteria for self-evaluation must be modified, unrealistic standards of
performance must be lowered, and self-esteem must no longer be based on
autonomous functioning or the managerial ability of the elderly person. Finally,
reintegration of goals
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and values necessitates revision of the aspirations of older people so that they
can find meaning and purpose in life as it presently exists for them.
Neugarten (1975) wrote that there is no single chronology marking the
transition from mature adulthood into old age, and suggested that older people
be divided into the young-old, who range from (fifty-five to seventy-five years
of age) and the old-old (over seventy-five years of age). Botwinick (1981)
suggested five groupings: the young-old (fifty-five to sixty-five years of age);
middle-old (sixty-six to seventy-seven years of age); old-old (seventy-eight to
eighty-four years of age); and the very old (eighty-five years of age and over).
The use of differentiated age categories reduces the margin for error inherent
in sweeping generalizations of the over-sixty-five population.
Although the young-old group is likely to be healthier and more functional than
the very old, it remains necessary, in many instances, to rely on data based on
broad categorizations of the elderly. Among the misconceptions concerning the
elderly population, the following ideas are prominent: most old people are
lonely and neglected; most old people are sick and dependent; and most old
people live in nursing homes or other institutions. These prevailing myths are
not supported by facts. The majority of elderly people not only maintain
independent lives, but have access to support systems comprised of relatives
or friends.
There are, however, undeniable demographic trends that have a profound
impact on elderly people and the middle-aged offspring who assume primary
responsibility for their care. The U.S. Bureau of the Census reported that there
were 9.1 percent more people between sixty-five to seventy-five years of age in
1985 than in 1980. There were 14.2 percent more people from seventy-five to
eighty-four years of age, and 21.0 percent more people over the age of eightyfive in the same five years. Other important influences, in addition to increased
life expectancy, are later marriages, decreased fertility rates, and large
numbers of women in the labor force. Although family members endeavor to
provide some care to elderly relatives, fewer family members are available to
discharge this responsibility (Pett et al., 1988). By the year 2010, one-fourth of
the U.S. population will be over age fifty-five, with 14.3 percent over age sixtyfive. By the year 2050, 33 percent of the population will be over age fifty-five,
with 24 percent over age sixty-five (Kermis, 1986).
Retirement Crises
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1962).
Women who were full-time homemakers and women who worked outside the
home seemed to find retirement a less dramatic change than did their
husbands. Since women of retirement age relinquished the important
mothering role when the last child was launched, they may have learned
adaptability. A major adjustment women identified after retirement was
pressure to engage in social and domestic activities as a couple rather than as
individuals. Loss of privacy was identified as a
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range view of their jobs and discern changes in the way others view them. At
the same time, they engage in fantasies of what retirement will be like. When
the fantasies are realistic, they can be helpful in determining issues to be
faced. When the fantasies of the preretirement phase are unrealistic, the
actuality of retirement may be disillusioning. The time just after formal
retirement is usually satisfactory, and for some retirees it remains pleasurable.
Others are unable to sustain their original satisfaction and react to
disenchantment by restructuring their time in order to deal with their options.
For some retirees this may mean returning to full
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raised may be too large or too expensive for a retiree to maintain. Even when a
retiree is reluctant to make immediate decisions, it is helpful to consider various
living arrangements. Use of leisure time is a retirement aspect that may not
receive much priority, but deserves serious consideration. Hobbies,
volunteering, or part-time work are possibilities for spending leisure time
constructively and enjoyably. Retirement usually reduces the number of
interpersonal relationships available, because many relationships depend upon
shared work experiences. In spite of the best efforts of everyone concerned,
work-related associations weaken in time, as shared interests and memories
fade. This means that family ties may become more important, and that new
sources of friendship must be found. Church affiliations, lodge membership,
and community organizations may provide the interpersonal stimulation the
retiree has lost.
There are certain differences in the life experiences of men and women that
operate to make retirement years easier for women. For men, the prime years
of career achievement occur between the ages of thirty-five and fifty, after
which it seems to decline somewhat. For women, career achievement may be
secondary during the childbearing, childrearing years, but become primary as
the children become more independent. This means that many women are still
invested in career goals when their husbands are beginning to look for
gratification within the family, as career demands lessen for them.
The role of wage earner is a source of self-validation for most people; paid work
gives one a sense of identity, importance, and purpose, and the onset of
retirement brings an end to much of this, especially for men accustomed to
define themselves only in terms of wage earner. Aber (1992) found that paid
work was a critical factor in the adjustment of older women after the death of a
husband. Having a paid work role identity, in addition to a wife and
homemaker identity, was a positive resource for widows during the
bereavement period. One possible explanation was that the role of wage
earner provides individuals with confidence that they have the ability to
surmount stress and challenges that come their way. The protective aspect of
the wage earner role also indicates how deeply men may feel its loss as they
move into retirement. Women, especially those committed to job or career, also
suffer role loss. However, many women consider their wage earner role to be
secondary to their roles within the family.
Just after his sixty-fourth birthday, Bob Jackson suffered a myocardial infarction
while working in the factory where he was plant foreman. Taken by ambulance to
the nearest hospital, Bob spent several weeks in intensive care before being
transferred to
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a medical floor. After four weeks of hospitalization, he was discharged with the
provision that he would return three times a week for cardiac rehabilitation.
Bob was a big, jovial, outgoing man who was emotionally shaken by his illness, but
soon rallied and became his customary cheerful self. In the hospital and just after
discharge, he followed his regimen faithfully, stating resolutely that he intended to
be back at work in a few months. In spite of his compliance, Bob's recovery was not
complete. When he filed a request to return to work, his application was rejected,
partly because Bob's physician recommended only limited exertion. Bob had worked
for the same company since graduation from high school and he had over forty
years of service to his credit. His three children were grown and self-supporting;
with his company pension and social security, Bob's income was adequate for
himself and his wife. Mary, his wife, was an accomplished musician who augmented
the family income by giving lessons at home.
When he was not permitted to return to work, Bob's reaction was one of outrage.
He appealed the decision, but, lacking the unqualified endorsement of his physician,
he was powerless to change it. Without advance warning or time to adjust, Bob
found himself an involuntary retiree. Soon after his enforced retirement, he
discontinued his visits to the cardiac rehabilitation center. He began to be absent
from the house and spend long hours at a local tavern. He grew indifferent about his
appearance and irritable with Mary when she protested about his habits. In the
past, Bob had been proud of Mary's musical talent, but now he complained about
students coming to the house and ridiculed the "cat calling" that Mary called singing.
Mary made some desultory attempts to reason with Bob, but in a very short time
she rented rooms in a nearby dance studio and moved a piano there so that she
could give lessons without disturbing Bob. The couple settled into a routine in which
Mary did her housework in the morning and left for her studio about noon. Bob
spent the mornings in bed and the afternoons at his favorite tavern. When the
couple's oldest daughter came home for a visit, she observed the impasse of her
parents and insisted that they see a family counselor. Their daughter made the
appointment and drove them for their first visit to make sure they kept the
appointment. Bob's response to his daughter was to say that things were never
going to be any better for him and that Mary was "king of the hill" now. Mary's
rejoinder was that Bob was a sick man and that she would do what she could to
help him, even if he had driven her and her students from the house.
Bob's illness frightened him, and he was unprepared for his sudden retirement.
Basically, Bob was a man who feared being dependent and therefore denied his
feelings to himself and to others. He camouflaged his anxiety and depression by
being difficult and demanding, and his wife misread his responses. While Bob
struggled with loss of his work role, Mary made an impulsive move that increased
the psychological distance between them. She did not consult Bob in advance nor
consider the
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effect of her action on his fragile self-esteem. Her behavior was a reaction to Bob's
displaced hostility and only increased his feelings of abandonment.
Although surface harmony had existed between Mary and Bob for many years, each
of them had led separate lives. For Bob, the factory and his job formed the social
center of his world. In many ways he had allowed Mary to make decisions about the
house and children without expecting to be consulted. Through the years he had
been proud of her musical ability and of her domestic efficiency. Her competence
and self-sufficiency threatened him only when he had no external sources of
satisfaction. The company's refusal to let Bob return to work robbed him of
direction, since his job as foreman confirmed his self-concept. Denying his feelings
prevented Bob from asking Mary directly for help. His behavior alienated her, and
loneliness aggravated Bob's anxiety, which he disguised behind irritability and heavy
drinking.
While Bob was a hospitalized patient, Mary was attentive and devoted, but when he
was unable to resume work, she was as disappointed as her husband. She was
accustomed to having her home to herself during the day and had acquired an
impressive number of pupils. Once or twice a week she met with women friends for
lunch or a game of bridge. With Bob at home all day, Mary found her freedom
curtailed and her privacy invaded. Bob began his retirement by assuming that he
and Mary would have breakfast, lunch, and dinner together every day, even though
this did not fit into her routine. At no time did the couple really try to discuss their
changed situation. Mary realized that her pupils annoyed Bob, but she did not
consult him about rescheduling the lessons at times convenient for them both.
Mary believed that Bob's retirement had disrupted her life as well as his, and she
was reluctant to compromise. Bob, in turn, thought that Mary should compensate
him for the gratification that had vanished with his job. At the very time when he
faced decremental losses, his wife made an incremential gain by moving her
lucrative music lessons outside the home. Throughout their married life the couple
had maintained different interests, each finding friendship and gratification outside
marriage. Bob spent most of his spare time with pals from the factory, whereas
Mary associated with a small group of women who shared her interests. Bob
bowled, Mary played bridge; Bob enjoyed baseball games, Mary preferred concerts.
Each accepted the other's differences and arrangements worked well until Bob's
retirement upset the balance.
Critical Guidelines
The isolation unexpectedly forced on Bob meant that the couple had to reconcile
some of their divergent interests. Neither could be asked to give up accustomed
pursuits altogether, but some compromise was necessary. The family counselor
agreed with the couple that there were favorite activities that they could
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continue to enjoy individually, but Mary needed to include Bob in some of her leisure
activities because of the emptiness in his life. A trade-off was recommended, with
Bob agreeing to learn bridge if Mary was willing to be introduced to baseball. Bob's
bowling and Mary's concerts were seen as areas for future negotiation by the
partners. Several of the six family sessions were devoted to effective communication
techniques the couple might use in the future. Bob was advised not to depend
entirely on Mary but to move out into the community in order to find companionship.
He was encouraged to join the retirees' association of his company and become
involved in their social and charitable activities. After attending several meetings,
Bob came home and informed Mary delightedly that he had been invited to join the
R.O.M.E.O. Club-Retired Old Men Eating Out Club.
The medical treatment Bob had received was excellent, but his psychological
wounds were ignored, particularly by his wife. Mary had behaved much like a
hostess with an unwelcome guest, forgetting that Bob had few resources currently
at his disposal. Conscious of additional cooking and housekeeping tasks, she was
quietly resentful of Bob's enforced retirement. Yet she was insightful enough to
realize when it was pointed out to her that restoring equilibrium in the marriage
depended on compromise and sharing. Self-engrossed for many years, the partners
were persuaded to give more to each other. Mary was encouraged to look beyond
Bob's drinking and blustering, and recognize his anxiety and depression. Theirs had
been a marriage based on separateness, and the counselor respected the
differences in the couple. During the retirement period, however, some
readjustment was necessary for the relationship to survive. With the help of the
counselor, more open communication was instituted so that neither Bob nor Mary
continued to act out their conflicts but could articulate what each wanted from the
other.
Relocation Crises
The attempts of families to provide a home for elderly relatives incapable of
living independently have received some negative attention. Present
generations are inclined to forget that immigrating to the United States often
meant leaving parents and grandparents behind. In those days people
generally did not live as long, and there were few resources for the elderly in
the form of social security benefits or long-term-care facilities. Therefore, family
care was the only alternative for the disabled elderly, except for public charity.
Surroundings are extremely important for the elderly because they spend a
great deal of their time at home. The quality of their residential environment in
terms of convenience, safety, and comfort is an important influence on their
sense of identity and well-being. Elderly people who are healthy and possess
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the homes where they raised their children, to move into smaller quarters, or to
relocate in retirement villages in gentle climates. Each of these alternatives is a
risk of sorts, particularly when a decision to relocate means giving up family
ties, old friends, or cherished possessions. Many older persons are reluctant to
move their place of residence even when there are compelling reasons. Faced
with undesirable conditions, on one hand, and opportunity for improved
housing, on the other, many elderly persons choose to stay where they are.
Resistance to mobility may be due to fear of change, income constraints, or
strong attachment to familiar surroundings.
Change of residence is a stressful experience for almost everyone regardless of
age, but two factors are especially significant: (1) the reason for the move, and
(2) the distance involved. Moves that require massive geographic change
cause higher amounts of separation anxiety. When the move is due to
advancement or promotion, stress lessens, but the most important issue is
whether the relocation was voluntary. Relocation of the elderly had great
negative impact when the decision was involuntary. Research on the effects of
relocation on the social adjustment, physical health, and mortality of the elderly
is inconclusive and permits the assumption that the elderly, like other people,
adjust to relocation in individualistic ways (George, 1980).
Only 5 percent of the elderly presently live in institutions, but projections
indicate that 25 percent of them will be institutionalized at least temporarily.
The crucial variables that determine institutionalizing an elderly parent seem to
be family tolerance of the effects of retaining the elderly person at home, and
commitment to the ideal of filial obligations (Atchley, 1988). Aged persons,
especially after they have entered a nursing home, are generally regarded as
useless and unproductive. They are assumed to be the recipients of care rather
than the providers of care. There are, however, a few studies showing that a
moderate proportion of nursing home residents seek opportunities to reach out
to others in helpful ways, despite their own experience with loss and
impairment (Hutchison & Bahr, 1991; Springer & Saylor, 1984). Nursing home
residents were found to offer caring behaviors in four categories of behavior:
protecting, supporting, confirming, and transcending.
Protecting behavior took the form of shielding other residents from possible
injury through verbal warnings, physical support, or soliciting help from the
staff on another's behalf.
Supportive behavior took the form of comforting, listening, and promoting selfesteem in others. Confirming behaviors consisted of recognizing and respecting
the personhood of others. These actions included visiting bedridden people in
their rooms or sharing food on occasion. Although limited by their own
infirmity, many residents folded laundry, worked on crafts for the annual
bazaar, or pushed wheelchairs.
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Two-thirds of primary caregivers for the elderly are female relatives (Kaye &
Applegate, 1990), but current research suggests that men are increasingly
involved in the care of elderly parents and spouses. Because
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more women than men are victims of Alzheimer's disease, husbands are very
likely to be primary caregivers for this group. This is consistent with the idea
that men become more androgynous as they reach middle-age, and are
therefore more willing to offer care. Although Kaye and Applegate (1990)
found that male caregivers performed multiple tasks, ranging from running a
household to administering personal care, the men derived least satisfaction
and felt themselves least competent in the area of personal care for the
dependent person. An interesting finding was that caregiving was easier for
men when they or the care recipient initiated affectionate gestures. This
argues against labeling men as emotionally cold and undemonstrative, and
supports the notion that the androgyny of middle and later years facilitates
caregiving by men. One of the most salient findings in this area, however,
indicates that men tend to cope with stress by using strategies that seek to
alter problems through instrumental action. Women, on the other hand, are
believed to rely more on processes that regulate emotional reactions to
stressful situations (Borden & Berlin, 1990).
Most couples are able to adjust to the additional role transition that follows the
deterioration of aged parents. If relationships between the two generations are
good, and the interdependence of the married couple is sound, this period of
role reversal will be less trying. Realization of the cyclical nature of life is a
factor that alleviates the turmoil of caring for aged parents. Mature couples
tend to treat their own parents as they would wish to be treated in turn.
According to Neugarten (1973, p. 98), one well-adjusted middle-aged woman
described her awareness of her place in the parade of generations as, "It is as
if there are two mirrors before me, each held at a partial angle. I see part of
myself in the mother who is growing old, and part of her in me. In the other
mirror I see part of myself in my daughter ... It is a set of revelations that I
suppose can only come when you are in the middle of three generations."
Clinical Example: Three Generational Household Interdependents
Viola Briggs and her husband, Jim, are the parents of three children, two boys and a
girl. When their daughter and older son were high school students and the younger
boy was in fifth grade, Viola and Jim were beginning to look forward to a few years
of relative freedom as the older children prepared to enter college. Their dreams
were interrupted when Jim's father died after a long illness and his mother came to
live in their home. Jim's mother was in relatively good health, but she was a
querulous, demanding woman with whom Viola had quarreled in the past.
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mother to live independently, even if she had wished to do so. Viola was reluctant
to accept Jim's mother as a permanent resident but felt she had no choice. Jim's
only sister was married to an engineer whose work made it necessary to live
overseas.
Always very talkative, Jim's mother constantly intruded when family members
brought friends home to visit. She was critical of her daughter-in-law's housekeeping
and childrearing methods. With the children of the family she was controlling and
intrusive. In a short time the grandchildren stopped bringing their friends home and
began socializing elsewhere. This added to Viola's resentment. She complained a
great deal to Jim, who reacted by becoming distant and withdrawn. A previously
happy household became contentious and discontented.
Viola had a girlhood friend, a social worker, who could see the problems objectively.
When Viola confided in her, the friend suggested counseling for Viola and Jim in
order to deal with a situation that seemed to grow worse every day. Counseling
sessions gave the couple an opportunity to express their feelings without becoming
angry and dysfunctional. Viola was surprised to learn how guilty Jim felt for placing
the burden of caring for his mother on his family. Until Jim openly expressed his
feelings about having sole responsibility for a parent he had never been close to,
Viola believed that her husband and his mother had forged an alliance that excluded
her. The positive feelings that Viola and Jim had for each other, and their wish to do
what was right while regaining family harmony were hopeful signs.
Counseling sessions focused on how to integrate Jim's mother into family life so that
her presence would not be disruptive. Practical arrangements were attended to first,
since these were easy to solve. Jim indicated that his sister was far more affluent
than he, and could contribute to the support of his mother if she chose. However,
she had not volunteered to do so and Jim had not asked for help. Since this aspect
of the situation was especially hard for Viola to endure, the counselor suggested
that they might approach the sister and directly tell her that financial help for
mother's care would be welcome. Jim and his sister negotiated the details, and it
was arranged that his sister would send mother an allowance, out of which she
would pay a small sum to Jim and Viola. This arrangement was extremely valuable.
It removed some pressure from the son and daughter-in-law, and it gave the
mother a sense of independence that alleviated her tendency toward self-pity and
martyrdom.
Viola had been planning to take a job as a salesclerk to help with the older
children's college expenses. When her mother-in-law came to live with her, Viola no
longer felt free to do this, yet Jim's mother was in fairly good health and did not
require full-time care. Jim, with the counselor's encouragement, assured Viola that
she could carry out her plan. Viola was ambivalent because she feared that if she
took a job, her mother-in-law would take complete charge of the household.
Acknowledging that this was a possibility, the counselor suggested that family
meetings be held to establish ground rules for everyone when Viola started her job.
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The meetings were surprisingly effective. With Jim as family spokesperson, Viola's
role as mother, homemaker, and decision-maker was reinforced. The older children
could see advantages in having more money available and promised their
cooperation. The younger boy, who rather liked his grandmother, said that it would
be nice to have someone in the house to greet him after school. The person who
was most receptive to the idea was Jim's mother, who saw that the family
reorganization would give her a place where her contributions would be needed.
Of course, there were times when Jim's mother was difficult. Viola and Jim had to
remain united as household heads inorder to prevent the older woman from taking
over. The reorganization worked because the self-esteem of the members was no
longer jeopardized by the grandmother's presence in the home. Receiving a regular
allowance from her daughter allowed Jim's mother to be independent and even
generous, at times, to her grandchildren. Together, Viola and her mother-in-law
prepared the week's menus; because she prepared the evening meal, Jim's mother
received a small sum from Viola. The older woman continued to pay for room and
board because, as she explained, ''I can have more to say about planning the
meals."
Critical Guidelines
Because Jim and Viola had a functional marriage, they were able to use the limited
counseling sessions to their advantage. After talking with each other, they found the
courage to impose rules for all family members and to set limits for Jim's mother
that benefited everyone involved. This was a caring family, but they were not
accustomed to sharing feelings, nor to attacking problems directly. In changing their
behaviors, Viola and Jim modeled a new way of dealing with each other that
eventually modified the behaviors of other family members, including the
grandmother.
One of the basic needs of all persons is recognition of their human dignity, and this
need does not disappear with age. One way that human dignity finds expression is
through the maintenance of activity and independence. Therefore, it is important to
permit the elderly to feel useful and in control as much as possible. All too
frequently, people live in progressively restrictive environments as they age.
Although some restrictions may be necessary, the elderly should be allowed control
over their possessions and should be given choices as long as they are able to make
reasonable decisions. Until the moment of death, people need to feel that their
wishes and preferences will be respected whenever possible. Although the aging
person values independence, interdependence is also a human need. To be
interdependent means to be involved in a mutually rewarding exchange with one or
more people. Interdependence means giving and taking, and sharing. Forming
interdependent relationships is one way of preserving human dignity and
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The decision to place an elderly relative in a long-term care facility is not easy for
families. Most nursing home residents are old, female, and white. The degree of
disability is not the major influence on institutionalizing the elderly; more reliable
predictors are the lack of reliable support systems and filial commitment. Regardless
of the extent of disability, older people from black families or traditional ethnic
groups are more likely to remain with their families (George, 1980).
The implications of institutionalization are painful for most elderly persons.
Placement is a clear statement that the elderly person is no longer considered fully
competent. Personal preferences must be left behind on entering an institution.
Privacy is curtailed, possessions relinquished, and choices about food or dress
become subject to institutional control. One cannot choose one's neighbors;
propinquity is thrust on the elderly, even to the extent of sharing a bedroom with a
stranger.
The average age of persons entering nursing homes is eighty-four years, and four
out of ten are over eighty-five. An average stay in nursing homes lasts eighteen
months; for residents in the lower age range, institutionalization is not necessarily
permanent. Through rehabilitation, more than half the residents eventually leave to
resume more independent lives. It is essential, therefore, that the type of facility be
appropriate to the individual's needs. Professionals involved in crisis or long-term
work with the elderly should be familiar with the services offered by different types
of facilities.
Types of Facilities
Residential
Residential facilities offer minimal supervision, room, board, and planned
activities. They are appropriate placements for persons who need some help
with activities of daily living, but do not require nursing or medical care. Such
facilities are not usually covered by Medicare or Medicaid.
Intermediate Care
Intermediate care facilities constitute the majority of nursing homes and are
eligible for Medicaid reimbursement. Some form of nursing care is available for
persons under the supervision of a physician, but the care may range from
admirable to deplorable.
Skilled Nursing
Skilled nursing facilities are recognized for Medicare and Medicaid coverage,
and may be accredited by the Joint Commission on Accreditation of Hospitals.
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low incomes and few resources; it pays for most medical expenses, including
nursing home costs
Medicare. This program enrolls anyone over sixty-five years of age; it is a twopart program that covers hospital and medical costs up to certain limits.
Persons under age sixty-five who receive social security disability are also
covered. Medicare does not cover long-term nursing home
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Figure 9-1
Financing of Long-Term Care for the Aged
Source: U.S. Health Care Financing Administration (1989 data), Washington, D.C.
Page 220
33 W. 42nd Street
New York, NY 10036
The Self-Help Center
1600 Dodge Avenue
Suite S-122
Evanston, IL 60201
National Support Center for
Families of the Aging
P.O. Box 245
Swarthmore, PA 19081
Clinical Example: Nursing Home Placement of an Elderly Parent
The Grady family consisted of the parents, Jim and Jean Grady, five adolescent
youngsters, one of whom was in college, and the grandfather, who had moved in
after the death of his wife eight years previously. Until the last two years, the
grandfather had been a resourceful, self-sufficient family member, always willing to
stay with the children when his daughter and son-in-law wanted a night out. Shortly
after his eightieth birthday, the grandfather began to change in ways that were
subtle at first, but became blatant. Although he was a diabetic, he became a
habitual refrigerator raider, especially at night when the family was asleep. He was
forgetful, confused, and amnesic concerning his nocturnal raids. Always a reticent,
quiet man, he was now very garrulous. When other family members entertained
friends, he was intrusive and repetitive. In a short while the grandchildren stopped
bringing their friends home and began socializing elsewhere.
Because the grandfather was her father, Jean Grady was inclined to be rather
tolerant of his idiosyncrasies. More and
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more often she found herself in the position of trying to restrain her father while
apologizing to her husband and children for his behavior. As time passed, the
grandfather became increasingly unmanageable. He began wandering through the
neighborhood, getting lost several times, and neighbors or the police returning him.
Occasionally he was incontinent, especially after he had generously helped himself
to forbidden alcohol. One morning when Jean was working in the garden, the
grandfather accidentally started a kitchen fire, which firefighters had to extinguish.
Jim Brady was an easygoing man, but as the grandfather began to need constant
supervision, Jim issued an ultimatum to his wife, "Either your father leaves this
house within the next month, or the kids and I will."
The Grady family loved the grandfather and felt guilty because they resented the
tension his deterioration brought into the home. They had always been a family
with a tradition of taking care of its members. Jim's mother had moved in with them
in the last months of her life, as she battled cancer. For most of their married life,
Jean and Jim had devoted their energies to the family, working and sacrificing to
fulfill paternal and filial obligations. Even though they still had five children to send
through college, they were beginning to anticipate the years when their obligations
lessened and they would have more time for themselves.
Jim's ultimatum regarding Grandpa was partly selfish, but he was also worried about
the strain on his wife and his children's estrangement. Having taken a firm stand,
Jim then became very supportive of Jean, and promptly began to investigate
facilities where the grandfather might be placed. There were times when Jean felt
angry with Jim as they visited various facilities, but inwardly she was a little relieved
that a difficult decision had been eased.
Jean had a close friend who was a social worker and who was willing to accompany
the couple on their observational tours. Following the advice of her friend, Jean
compiled a checklist of things to look for on her visits. The checklist included the
following considerations (Kayser-Jones, 1989):
Environmental factors. Are the rooms cheerful, spacious, and clean?
Costs and accreditation. Are expenses manageable, given the grandfather's income
and resources; is the facility currently accredited, on probation, or unaccredited?
Nursing care. What is the ratio of nursing staff to patient population; how many
registered nurses are on duty per shift; are nursing attendants certified?
Medical supervision. Is an institutional physician in charge of medical care for all
residents or may their private physician continue to monitor their care?
Dietary considerations. Is a trained dietition in charge of meal planning and
preparation; are residents' preferences given sufficient consideration?
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Programs and activities. Are the programs and activities appropriate, and based on
the skills and interests of the residents; do qualified personnel plan and administer
the activities' program?
Social amenities. What laundry facilities are available; are residents permitted to
hang pictures or have favorite objects in their rooms?
Philosophy and policies. What is the staff's attitude towards visitors or to
suggestions from family members; are there provisions for church services or visits
from the clergy; do all staff members treat residents with dignity and respect?
Critical Guidelines
The facility the family eventually chose was a skilled nursing home that the county
health department supervised. It was located two miles from the Grady residence.
The family took the grandfather to see his new quarters a week before placement.
The family told him of the impending change and reassured him that they would be
very near. The grandfather seemed to understand that he was leaving the family
home, but he talked vaguely of just going on a visit. Jean was very upset during the
week that her father was due to leave. Because she became tearful every time she
thought about the prospect, Jim prevailed upon her not to go with them to the
nursing home on the day her father was admitted. Therefore, Jim, Jean's friend, and
two grandchildren accompanied the grandfather to the nursing home. When the
time for departure came, Jean clung to her father, and the family members were
glad she had been spared the ordeal of escorting her father to the facility. At the
suggestion of the nursing staff, Jean agreed to wait a day or two before visiting so
that the staff could help her father accept his new surroundings.
The Grady family regained equilibrium shortly after the grandfather was placed in a
long-term-care facility, but his long-term adjustment remained an unknown. There
was no doubt that his physical and behavioral deterioration had increased the
tensions within the family system. Even a daughter as loving and conscientious as
Jean was unable to supervise his regimen, and the grandfather's regressive actions
were hastening his own decline. The grandfather embarrassed the children and Jim
was impatient with the sacrifices being asked of his wife and himself. In her more
honest moments, Jean admitted to feeling a sense of relief after her father left the
household. The care facility had been carefully chosen and was near enough for all
family members to visit frequently. There was no doubt that the nursing staff could
monitor the grandfather's physical problems more efficiently than Jean. Reality
orientation and resocialization techniques seemed, for the present, to have arrested
further cognitive deterioration for Grandpa. His general condition was stable, and
there were no signs that the placement adversely affected him. The relationship
between Jim and Jean was more harmonious, and the Grady home was again being
used for teenage gatherings.
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Loss Crises
A realistic fear of elderly persons is loss of a husband or wife through death.
Older couples inevitably entertain thoughts of what life might be like without
the partner, and the thoughts stir feelings of fear and anxiety. Females over
seventy-five years of age more often experience the state of widowhood, since
women usually live longer and marry men a few years older than themselves.
When family dissolution occurs because of the death of a spouse, there is an
end to the marital life cycle and the emergence of a new role for the surviving
spouse, that of widow or widower. The survivor, most often the wife, suffers
multiple role loss as companion, lover, confidant, and partner. Beyond role loss,
the survivor also must endure the reality of no longer sharing, belonging,
nurturing, or being needed. Death of a spouse causes extreme disruption in
the survivor's lifestyle. Even in the best of circumstances, painful adjustment
must be accomplished. Sometimes the grief of the surviving spouse is denied
or avoided to the extent that feelings of depression and ideas of suicide
become dominant (Botwinick, 1981).
Attachment between elderly couples with a shared life history tends to be very
strong. When a spouse dies, a highly cathected object is lost and the survivor
must redistribute the cathexis. In less psychoanalytic terms, this means that
the emotional attachment invested in the deceased must eventually be
withdrawn and the energy reinvested in other attachments. This process can
be difficult and protracted for many individuals. Older widows often view the
death of the husband as the end of their status as a wife and partner, with
resultant lowering of self-esteem and self-identity. With widowhood, most
women must relinquish a role central to their existence and adjust to the
absence of the one individual who could best validate their self-image in terms
of personal attributes. Furthermore, the social status of women, especially
older women, is largely dependent on the occupational success of the
husband. With the onset of widowhood, this derivative identity is dissipated;
new social roles with new demands and expectations are thrust on the widow.
After years of interdependence, she must learn how to live independently and
how to enact a solo role in the social environment.
Widowhood contains the potential for an identity crisis, especially for elderly
women, but fortunately, this potential can be alleviated in many cases.
Memories and material possessions accumulated during the years of a marriage
can help wifehood retain significant meaning for widows. Children and
grandchildren can be powerful reinforcers to the identity and self-esteem of the
widowed elderly. Adjustment to widowhood is not the same for everyone. Not
every woman gives equal value to the role of wife and mother. For many
women, the role of mother overshadowed that of wife, and when the children
left home, both roles were
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numbers of men are widowed, and even then, men are less likely to face an
identity crisis due to loss of the husband role. There are problems, however,
that are uniquely masculine during widowerhood. Widowerhood drastically
alters conditions of retirement for elderly men, and they experience more
difficulty managing daily routines during the early grief period. Widowers seem
to be more distant from their families than widows, so that loneliness and loss
of an important confi-
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dant is a serious problem for widowers. Since they are less prepared to assume
housekeeping tasks, widowers are more likely to give up their own residences.
The surplus of widows over widowers poses both a problem and a solution for
men. Some men are inhibited in their socializing and in their participating in
community affairs because women so outnumber them. In many respects,
such as their health and general adjustment, men find widowerhood more
difficult than their female counterparts do. Redeeming features of
widowerhood include the facts that men are likely to have higher incomes,
enjoy more opportunities to develop friendships, and are more apt to remarry.
Atypical grief reactions exhibited by the elderly may be classified as delayed,
distorted, inhibited, and chronic. A delayed grief reaction is shown in situations
in which grieving has been delayed until the anniversary of the loss or until a
significant experience activates realization of the loss. Distorted grief reactions
take the form of psychotic depressive or schizophrenic states. A less
pathological, but still distorted, reaction manifests itself when the survivor
identifies with the deceased and assumes behavior and mannerisms of the lost
one. Grieving in a passive fashion over a very long period is termed inhibited
grief. Chronic grief takes the form of long-term disbelief and shock that
resembles the temporary reaction observable in the normal initial stage of
grieving. The elderly most often display inhibited and chronic forms of grief.
Since these forms of grief customarily prevent open expression of mourning,
somatization through physical symptoms becomes a substitute way of venting
feelings.
The most common mental disability among the elderly is depression, a notsurprising finding in view of the many losses they sustain. Death of a significant
person is the most common cause of depression in the elderly, but other losses
can be crucial. Children moving away, giving up an accustomed residence, and
separating from friends or relatives are all forms of loss that may precipitate
crisis. Repeated losses may cause elderly persons to become reluctant to make
additional investments in people or events. Loss of vigor, productivity, or sexual
function are additional factors leading to depression and a sense that life is no
longer rewarding. When elderly persons withdraw emotionally from others,
they often project their own feelings of anger and disengagement to people in
the immediate vicinity. This projection contributes to a process of mutual
withdrawal in which disengagement of the elderly person progresses
alarmingly.
Elderly persons comprise only 10 percent of the total population, but 25
percent of all suicides occur in the over-sixty-five group. Females over sixty-five
years of age have a suicide rate twice the national average, while males in the
same age group have a suicide rate four times the national average. The
married elderly have a lower suicide rate than the
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unmarried elderly; 60 percent of the elderly who commit suicide have severe
physical disorders (Crandale, 1980; Goleman, 1985).
When the elderly attempt suicide, it is likely to be successful since the action is
rarely an attention-seeking tactic or a gesture to attract sympathy. The wish
for death is apt to be strong, and the elderly are people whose physical
conditions are rather fragile. Therefore, self-injury is more likely to have fatal
consequences for an elderly person than for a younger one. The social
disengagement and isolation of the elderly are additional factors that preclude
timely intervention in response to cues. Among elderly people, a single overt
act, such as shooting or hanging may accomplish suicide. Failure to take
needed medication, intemperate drinking, exertion, or other behaviors that are
fatal to individuals with known vulnerabilities may achieve covert or passive
suicide over time.
Suicide as a Grief Reaction
Death involves leaving and being left, and who is to say which causes greater
suffering. Acute and profound grief can play havoc with the mourner's reason
and sense of reality. In the case of a terminal illness, the task of the dying
person is clear, whereas the tasks of the survivors are less so. As Elizabeth
Kubler-Ross (1970, p. 142), a Chicago psychiatrist, observed, ''The dying
patient's problems come to an end, but the family's problems go on." KublerRoss encourages practitioners to interact deeply and extensively with the dying
person and the family, pointing out that professionals often view death as an
adversary whose arrival is met with denial and detachment.
After the death of a spouse, there are many psychological tasks for the rest of
the family to perform. The surviving parent may become overly preoccupied
with her own distress, and be unable to give much to the children, whose grief
around the loss may be equally intense. Frequently, the persistent needs and
demands of the children help the surviving parent to become less selfengrossed and to deal with pressing realities. People who suffer a loss
eventually learn that the passage of time considerably diminishes the acute
feelings of sorrow and loss.
The work of mourning the loss is the first order of psychological business for
the family, and is a complex, but necessary, process. Immediately following the
death of a spouse, there may be a period of disorganization in family life, but
this is to be expected, and most families eventually settle back into familiar
routines of daily life in the weeks following the funeral. The goals of caring for
the suicidal client are directed toward providing protection from selfdestruction until the client is able to assume that responsibility himself. It will
be necessary to assist the client to express
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college. The older boy wanted a career as a chemist, whereas the younger was
interested in pursu-
Page 228
ing a career in music. Reluctantly, the parents acceded to the boys' request that
they be allowed to attend the colleges of their choice.
After the boys left for college, Bill and Laura hired farm hands and tried to keep
things going, even though their hard work exacted a toll. Laura, in particular, began
to show signs of strain. When she suffered strep throat that first winter, an antibiotic
was injected to which Laura proved allergic. She suffered a severe anaphylactic
reaction at home; in spite of her physician's heroic measures and the local rescue
squad's arrival, Laura died without regaining speech or consciousness. The boys
came home for the funeral, were contrite and miserable, but did not offer to stay on
the farm permanently. After the funeral they returned to their respective colleges.
For a while friends and neighbors were quite attentive. Bill was invited out for
meals, the minister called, and church women brought over homemade soups and
casseroles. Even with this attention. Bill became more and more morose. He
described himself as an old horse who had reached the time to be put out to
pasture. Bill missed Laura, with whom he could discuss signs of changing weather
and make decisions about when to plow or plant. It was a different existence for a
man who loved the earth and the changing seasons, but had always shared his
thoughts and questions with Laura. The winter was slow in passing, but Bill hoped
he would feel less discouraged in the spring. The boys were due to come home for a
few weeks, and Bill anticipated their visit.
While his sons were home, the three of them worked together on the farm. As they
went about accustomed tasks, things seemed almost as they had always been. Only
at mealtime was Laura's absence painful for the boys, but out of consideration for
their father they did not mention their grief to him. During the evenings, the boys
were restless, talking animatedly to each other about subjects that were
unintelligible to Bill. Only when Bill was not present did they discuss their mother.
After the boys returned to school, the farm seemed lonelier than ever. Bill kept busy
but it seemed harder for him to concentrate on what had to be done. For years Bill
had risen with the birds, but now it was difficult to get out of bed in the morning.
Following Bill's example, the hired men became more lax in their work, and as
weeks passed the farm began to take on a neglected look. Bill became so irritable
and taciturn that his two helpers turned resentful, packed their gear, and left the
farm without giving notice. Finding himself completely alone, Bill became more
despondent. One early morning after feeding the animals and cleaning the barn, Bill
took out his rifle and shot himself in the head. A few days later the minister found
him in the barn. He had missed Bill at church services. A note was discovered saying
that the farm was to be sold and the proceeds divided between his two sons, whom
he wished well in their chosen occupations. "The farm was only important to my
wife and to me," he wrote. "Without her the farm is nothing and I am nothing."
Bill was in a state of crisis as a result of the death of his wife and separation from
his boys. Even though his minister, his sons,
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and his neighbors tried to be helpful, no one realized the acute distress Bill was
experiencing. Isolated on the farm, showing little outward emotion, unwilling to
burden his sons or confide in anyone, Bill sent to clear warning messages. For a
while the prospect of seeing his sons again sustained him, but when the reunion
ended, Bill's wish to join Laura in death was far stronger than his wish to live. In his
suicide, as in most matters, Bill discussed his plan with no one; and as usual, he
completed his plan.
Critical Guidelines
The Bennett's were a family who seldom expressed their feelings. The sons did not
share their own legitimate ambitions with their parents, nor did the parents try to
discuss their fears and disappointments with their sons. As a result, no one in the
family understood or reached out to other members. Too much emphasis was
placed upon independence and self-sufficiency. Bill and his sons all felt guilty about
Laura's death. The two sons did talk to one another on occasion and found some
solace in sharing, but they did not include their father. Bill, on his part, was all too
willing to turn away from his sons, as he had turned away from helpful neighbors in
the church and community.
The sons' indifference to the family tradition of farming was a blow to Laura and Bill
that they concealed from them. When Laura became ill, Bill blamed himself and his
devotion to the farm for her untimely death. An inarticulate man, he shared little of
his feelings with others, but was devoted to Laura. After her death, he began to
hate the farm and believe that the farm had robbed him of his wife and his sons.
When Laura died, Bill experienced an inhibited grief reaction. He shared his deep
sorrow and self-recrimination with no one, and his sons lacked the insight to help
their father express his feelings. Feeling guilty, they protected themselves by
avoiding open discussion of their mother's death and their own pain. As a result of
mutual avoidance, Bill's feelings found no outlet. He held his emotions within, and
as time passed, the inhibited grief reaction became a chronic depressive state.
Bill's suicide added to the guilt that the sons undoubtedly felt. Unlike Bill, they did
have one another and probably were less socially isolated than their father had
been. It is possible that their failure to resolve earlier issues with their parents
would complicate their mourning and grief work. Their prolonged failure to see that
their father was in crisis is a potential source of great pain and guilt. The
circumstances surrounding the death have much to do with the nature of the
grieving process. The process is also affected by the relationships within the family
before the death, which have the power to mitigate or exacerbate feelings of loss. A
conflictual and highly ambivalent relationship with the deceased family member can
complicate and prolong the mourning process for an individual or for the whole
family. Family members who never had the chance to resolve a hostile and guilt-
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alive are likely to experience a painfully prolonged mourning process that may last
for years, unless the person seeks therapeutic intervention.
Both public and private mourning are necessary in the working-through process.
Sharing the painful feelings of the grief and allowing friends to comfort relieves
feelings of isolation. A person also needs to grieve privately; the pain of the loss
needs to be experienced, and felt, since, when painful feelings are denied, or
pushed aside, emotional complications may follow.
Significant others may not be helpful or may even be injurious. If they reject
involvement and deny the suicidal behavior, the desolate person may withdraw
physically and psychologically from continued communication. Sometimes significant
others resent the client's increased demands and insistence on gratifying
dependency needs. In other cases, they may act helpless and indecisive, giving the
suicidal person the feeling that help is not available, thereby increasing her feelings
of despair. To help the situation, treatment for the significant others may be
indicated as well.
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decline may be overstated. Researchers have found that when the same
subjects were followed from adulthood into old age, the amount of decline was
far less than that found in studies that compared two different population
groups, one in middle adulthood and the other in old age. As Tavris (1987, p.
24) wrote, "The greatest difference in sexual activity-or any other aspect of
aging-is not between the young and the old, but between individuals."
The way society regards old age intensifies the maturation crises of the elderly.
Youthfulness is highly valued in American society, and fear of aging is
reinforced. Many individuals see in the elderly the prediction of their own
future, fear their own aging, and try to avoid accepting the later stages of the
life cycle until they must. This is unfortunate, because planning for the final life
cycle stage can help avoid or ameliorate some of the problems.
Adjustment to recurrent loss is a prevailing theme in the lives of older people.
In addition to the loss of youthful strength and vigor, and of friends and loved
ones, the elderly suffer role losses as their children become independent, and
as retirement arrives.
One of the most painful encounters with death is the demise of a spouse, for
this means the loss of a companion, confidant, friend, and lover. Because
women tend to live longer than men and to marry men who are somewhat
older, they are more likely than men to face widow-hood. Of course, not all
marriages are happy and not all partners find the role of husband or wife
congenial or central to existence. Allowing for these variations, a marriage
dissolved by death still brings strong feelings of grief and regret. Some widows
and widowers may idealize the deceased, forgetting her faults and
weaknesses. This may be disconcerting for those who have a more accurate
recollection of the deceased, but idealization is part of the grief process, and
distortion need not be corrected. When the mourner accurately perceives the
strengths and weaknesses of the deceased, it is likely that his grieving has
been completed.
While the federal government tries to deal with the problem of how to bear the
cost of caring for the elderly, family members continue to assume the burden,
especially the women. An important precept to remember is that caretakers
need relief, and the relief should be periodic, frequent, and available. Support
services should be used throughout the caretaking process, not merely in times
of crisis or when the primary caretaker is on the verge of collapse. Many
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strong case for voters to exert pressure on elected officials to integrate longterm health care, in the home or in institutions, into the reimbursement system
(Quist, 1989). In these days of expanded opportunities for women, many of
them looked forward to living in an empty nest that would finally allow them
time to develop interests and talents, either as volunteers or late-blooming
careerists. Instead, many women have found themselves caught between the
demands of a job and the arduous task of caring for a parent who is less than
competent (Wood, 1987).
Successful adaptation does not mean that the elderly person must enjoy the
limitations that age brings, but merely that limitations must not be denied.
With advancing age, control over one's social environment is threatened.
Personal space becomes circumscribed as certain activities and roles are no
longer accessible. Searching for alternative interests is part of adaptation, and
individuals who cannot give up total autonomy or accept some dependency fail
to adapt well to aging. Readjustment of criteria for self-evaluation means that
various criteria for self-evaluation must be modified, unrealistic standards of
performance must be lowered, and self-esteem must no longer be based on
autonomous functioning or the managerial ability of the elderly person. Finally,
reintegration of goals and values necessitates revising the aspirations of older
people so that they can find meaning and purpose in life as it presently exists
for them.
Old age is a time of loss-of self-worth, of role performance, and of significant
others. The perception that life is no longer meaningful becomes a reason for
ending that life. Displacement from job-related roles and family roles may
produce a feeling of hopelessness and uselessness. Widows and widowers are
particularly vulnerable, especially in the first year following the death of a
spouse.
Many suicide victims have feelings of loneliness, helplessness, and
hopelessness that a loss often aggravates. Suicides occur more frequently
among divorced people than among single people, and among single people
more frequently than among married persons. For the survivors, suicide is a
highly personal tragedy that produces feelings of pain, guilt, remorse, and
bitterness. Social isolation is another contributing factor. Women tend to have
a greater chance for survival because of the contact with friends and the
responsibility for integrating kinship groups.
There are sex differences in the methods chosen: men are more likely to
commit suicide with a gun, while women usually resort to barbiturates and
other less violent methods. Some experts feel that women use these methods
because they fear disfigurement or because society does not sanction violence
on the part of females. The clearest example of direct behavioral
communication is a suicide attempt, or "practice run."
Although it is commonly believed that clients who frequently attempt suicide
will never actually complete the act, a previous attempt is actually one of the
strongest indicators of potential suicide. For some, the
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Even more difficult than bringing an elderly relative to live in the family
household is the decision to place a feeble relative in a nursing home. Feelings
of guilt, anger, and regret are almost unavoidable, but searching for
acceptable solutions and making careful choices may somewhat alleviate these
feelings. Financial considerations certainly influence
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decisions, but such factors as geographic location, level of care, and the elderly
person's well-being deserve the utmost consideration as well.
Losing cherished friends and loved ones is a recurrent experience for elderly
people. In responding to any loss, grief and sorrow should neither be denied
nor avoided. Failure to engage in, or acknowledge grief, after any significant
loss, may prolong, intensify, or inhibit the adaptive effects of the painful, but
adaptive, mourning process. The inability or refusal to grieve often leads to
depressive reactions, which may generate suicidal thoughts and feelings. Such
ideation sometimes results in suicide attempts that succeed.
A number of experts have formulated frameworks depicting sequential stages
of grief. More important than these is the counselor's ability to recognize grief
in all its forms. It is essential to realize that bravado, withdrawal, or apparent
indifference may camouflage grief and mourning. It is important for crisis
workers to be aware of the many masks that grief may wear (Archer and
Smith, 1988).
When death is untimely or unexpected, or when the mourner feels responsible
in some way, the grief reaction may be more intense because guilt is added.
The age of the mourner also influences how grief is expressed and its extent.
Older people whose personal worlds have narrowed to a few cherished persons
or objects may feel especially desolate. Adolescents mourn much as adults do,
but younger children, whose cognitive and language development are
incomplete, have difficulty comprehending or expressing feelings of grief.
The younger a child, the more difficult the grieving process is. Since grieving is
a form of primary prevention against later depression, children need help from
family members. When children want to talk about a relative who has died,
they should be permitted to do so without being diverted. Adults who listen
ease the child's pain and may even find their own grief lightened. Denial of loss
and avoidance of grieving are defenses that are not helpful.
As in so many aspects of counseling, therapeutic intervention in response to
the crisis of loss consists of listening, observing, accepting, and validating the
experience of the troubled individual. A counselor can accomplish this when
she encourages reminiscing, reinforces the elderly person's sense of self, and
conveys honest respect for lifetime accomplishments, even if they took place
fifty years ago.
References
Aber, C.S. "Spousal Death, A Threat to Women's Health: Paid Work As a
Resistance Resource." Image 24(1992): 95-98.
Archer, D.N., and A.C. Smith. "Sorrow Has Many Faces: Helping Families Cope
with Grief." Nursing 88 18(1988): 43-45.
Atchley, R.C. Social Forces and Aging. Belmont, California: 1988
Page 235
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Page 237
PART THREE
FAMILIES IN CRISIS
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10
Marginal Families in Crisis: Illness and Disability
There is a tide in the affairs of men which taken at the flood leads to fortune. Omitted,
all the voyage of their life is bound in shallows and in miseries.
William Shakespeare
The limited nature and scope of crisis counseling sometimes pose a problem
that is compounded when a family rather than an individual is the focus of
intervention. One solution is to formulate short-term goals that give direction to
immediate problem solving, so that other issues can be dealt with later. Shortterm objectives can be formulated around the most urgent needs of a family as
it confronts illness, accidents, decisions, or conflicts that are unlikely to be
resolved quickly. With this restriction in mind, a family-oriented approach to
crisis work is appropriate. For example, a family dealing with the progressive
illness of one of its members may displace anger and bitterness toward the
patient's health care professionals. If caregivers respond in a defensive style,
the resentment that the family and staff express may impair optimum care of
the patient. In such a situation, crisis intervention could be used to explain
essential procedures to frightened family members and to assure them of the
staff's commitment to the patient. In addition, negative family behaviors should
be interpreted by caregivers as human reactions to a frightening situation
rather than a personal attack on hardworking staff members.
Fleck (1980) classified family functions into six groupings: marital, nurturant,
relational, communicative, emancipational, and recuperative functions. In
everyday life these functions overlap, although at various times one or another
function may be dominant.
1. Marital functions. Families begin as marital dyads within which each partner
hopes to receive gratification from the other. Accepting and
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sharing family leadership tasks are essential aspects of the marital function.
2. Nurturant functions. Nurture includes all basic care of children and
encompasses their security, protection, socialization, and sensory stimulation.
3. Relational functions. Accepting the critical tasks of family members requires
continuous adaptation so that parents and children can interact comfortably
with each other and with their respective extrafamilial peer groups.
4. Communicative functions. Communicative competence is essential for
human adjustment, and includes verbal and nonverbal messages. Family
communication must be congruent and consistent so that messages are clearly
understood. In addition, family communication should be compatible with the
linguistic customs of the surrounding community.
5. Emancipational functions. Emancipation of children from a family must
accompany the attainment of adult status, but the departure of each child
requires the parents and remaining siblings to adjust. Thus, every family must
deal with recurrent issues of individuation and separation as children grow up
and leave home.
6. Recuperative functions. Families provide a milieu in which members may
safely relax, regress, and recuperate from the demands and rigors of life
outside the home.
Friedman (1981) described the contemporary family as a unit whose major
function is mediation. Within its borders, the family mediates between the
individual and collective needs of its members. The family also mediates
between the needs of its members and pressures emanating from the suprasystems of society. For example, society imposes restrictions on when young
people may leave school to enter the work force, and defines parental
responsibilities by means of legal and community sanctions. Society also
monitors many aspects of health care delivery through professional licensing
and regulating certain treatment modes.
Whenever the total physical and emotional resources of a family are
insufficient, critical tasks and family functions are threatened. Disproportion
between family needs and family resources endangers group functionality.
Families who attempt to overcome disproportion by appropriate, but
inadequate, role enactment are called marginal. Families who attempt to
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and more deviant than marginal families, although both types of families are
likely to experience disequilibrium. Marginal families are those in which suitable
role enactment is attempted and barely maintained. Disorganized families are
those in which suitable role enactment is rarely attempted and never
maintained. In disorganized families, dysfunction is more obvious; in marginal
families, functionality seems to be present but is tenuous. As a result, marginal
families are extremely vulnerable to change despite their efforts to cope.
For purposes of this chapter, marginality is not a pejorative term but is largely
descriptive. A change of any kind makes new demands on individuals and
families. When the family's resources are adequate to deal with change,
equilibrium is preserved. Because marginal families have limited discretionary
resources in the form of energy and adaptability, their equilibrium is always
precarious. Whenever the balance between resources and demands is upset
and crisis follows, the experience is more painful because marginal families
entertain hopes of remaining functional.
One factor contributing to the marginality of families in modern life is
industrialization, which transformed extended families into separate nuclear
households in which the working unit is the solitary individual. Even in dualcareer marriages, the partners tend to be single units of production, each
pursuing an occupation independent of the other. Small nuclear families lack
the capacities of extended families for deflecting or absorbing hostility between
members, or for dealing with the hazards of illness or disability. When adverse
conditions are extended or severe, few relatives are at hand to provide help,
and nuclear households have no peripheral members to neutralize intrafamily
conflicts or assist with responsibilities.
Disorganized families usually live from crisis to crisis; this pattern is less true of
marginal families, although they are crisis-prone. Adding to the problems of
marginal families is the inverse correlation between the prevalence of illness
and high socioeconomic status. This inverse correlation may be partly caused
by the susceptibility of lower socioeconomic families to physical and mental
illness, and to their slowness in responding to early signs of malfunctioning.
There is no doubt that family perceptions of events influence their recognition
of conditions that merit attention and their subsequent actions. Families who
interpret all events as threatening, who magnify or minimize reality, and who
devalue or exaggerate their coping abilities are more likely to suffer crisis.
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Page 243
illness restricts activity but does not shorten the life expectancy of the sufferer.
Terminal illness is the phase of acute or chronic illness that ends in death,
usually after a fairly predictable course. The onset of all three types of illness
may be either sudden or gradual. Often the onset may appear to be sudden,
but the disease process has, in fact, been insidious and hidden. The family
must then deal with an advanced stage of illness of which there was no
previous knowledge.
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priority may be lacking. If the family has known that the illness was present for
weeks, months, or years before becoming acute, there may be feelings of
anger or guilt. If the illness has already caused role restriction for the patient,
negative feelings accumulated during earlier stages of the illness may
complicate an acute phase. A wife may feel that her husband knew he was
sick, but did not care enough for his family to take proper care of himself. The
ill husband may feel that family demands were excessive or that his wife should
have insisted that he seek
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medical care earlier. Each may displace feelings on the other that something
should have been done to prevent the development of acute illness.
Meanwhile, the children may react with fear and confusion to the realization
that the family provider is mortal and is in peril.
The family's ability to recognize and respond to early signs of poor health can
influence the course of the illness. A family's willingness to do this is a function
of personal, ethnic, and social variables. Families who enjoy an adequate
income are more able to pay for health maintenance, and to seek professional
help at the first indication of illness. Such families are generally sensitive to
changes in the health status of their members, and of adverse effects of failing
to act on early warning signals. At the other extreme are many marginal
families who define health only as the ability to work, and ignore signs of illness
until they are incapable of working.
The Sick Role
Individuals in the family, their internal relationships, and their willingness to
receive external aid influence their response to the crisis of illness or disability.
In more traditional times, life and death, health and illness were considered to
be one continuous process. All outcomes were attributed to the will of God,
and the promise of eventual reunion with the deceased somewhat relieved the
grief of survivors. In contemporary life, such comfort is less widespread.
Furthermore, for marginal families who already have little control over their
existence, the onset of illness or disability constitutes another reminder of their
limitations. Failure to deal well with stress or crisis then becomes part of a
familiar experience of feeling overwhelmed.
Marginal families are sometimes slow to recognize serious disturbance in a
member, but after acknowledging the symptoms, they make an effort to
respond (Minuchin, 1974; Minuchin et al., 1967). Many of these families first
try random solutions and intrafamily consultation before searching for
professional help. After accepting care from health professionals, an ailing
family member is expected to enact the sick role with its accompanying
exemptions and obligations. Depending on the identity of the family member
and the life cycle stage of the family, obligations of the sick role occupant may
outweigh exemptions. This pattern is especially true when it is the wife and
mother who becomes ill. Because the mother is crucial to carrying out daily
family routines, immediate readjustment is necessary when she is the ailing
member. When it is the husband and primary provider who falls ill, economic
deprivation may be an early consequence. In two-parent households,
reallocation of tasks is feasible, but role flexibility is a luxury unavailable in
single-parent homes, which
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comprise about 16% of all households in the United States (Bjornsten &
Stewart, 1985).
Observing the ways that families respond to serious illness or disability reveals
interesting variations. When a family member becomes chronically or terminally
ill without hope of recovery, other persons in the family are unlikely to look for
help with their own emotional problems, either because they do not relate their
problems to the illness, or because they hesitate to involve a person who is ill.
When illness continues without remission for a protracted period, families
become enmeshed in the schedules the illness necessitates and are unwilling
to delegate tasks. At the same time, there may be deep resentment for having
to be so attentive at the expense of individual fulfillment. Occasionally, a family
member will withdraw from those in the family who are well, existing only to
protect and nurture the ill member, ultimately becoming dependent on
enacting the caretaker role. When families are preoccupied with illness or
disability, life cycle tasks, such as separation, which are chronologically suitable
for younger family members, may be delayed due to the burden of caring for
the ill member (Collings, 1981).
Noting how families responded to ailing members, Parsons (1951) described
characteristics of the "sick role" and outlined the obligations and freedom from
obligations that accompanied enactment of the sick role. Society-at-large
generally shares the family perspectives of sick role exemptions and
obligations.
Exemptions of the Sick Role Occupant in Physical Disorders:
Exemption from responsibility for being ill.
Exemption from customary role obligations.
Obligations of the Sick Role Occupant in Physical Disorders:
Obligation to accept competent assistance.
Obligation to cooperate in the recovery process.
Obligation to be dependent, submissive, and compliant.
When Parsonsian concepts of the sick role are applied to mental illness, other
discrepancies become apparent. In effect, enactment of physical and
psychiatric sick roles are contradictory in the exemptions and obligations
extended to the occupants. It may be stated that sick role concepts are more
readily applied to physical illness than to psychological or psychophysiological
disorders. In other words, viewing individuals as suitable occupants of the sick
role is unlikely when the illness is not considered fully somatic in origin and
expression. Whenever a purely somatic disorder is present, the patient is not
held responsible for being ill. When the disorder has overt psychological
overtones or is thought to be the result of deviant social behavior, such as
alcoholism, the sick role
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occupant may be held accountable for causing, as well as coping, with the
disorder.
Exemptions of the Sick Role Occupant in Psychiatric Disorders:
Partial responsibility for being ill.
Partial exemption from customary role obligations.
Obligations of the Sick Role Occupant in Psychiatric Disorders:
Obligation to accept competent assistance.
Obligation to cooperate in the recovery process.
Obligation to be adaptive, interactive, and self-directed.
Obligation to accept the stigma of a psychiatric label.
It is evident from this discussion that enactment of the sick role is not
consistent or unidimensional. The nature of an illness, the identity of the ailing
family member, and the context in which the illness develops are factors that
determine how the sick role is enacted and how other family members relate to
the role enactment of the afflicted member.
Factors other than the prognosis of the illness affect the enactment of the sick
role. Insufficient attention has been given to variations of sick role behavior
among different populations and families. This neglect may be due, in part, to
the ethnocentricity of practitioners, who represent the mainstream of society,
or to a sincere, but misguided, wish to avoid stereotypical judgments.
Risk Factors
Indications of effective family functioning are fairly easy to recognize. Open
communication, nonexploitive attachments, and willingness to compromise are
essential to performing the core tasks of family life. Dysfunctional families do
not engage in open communication, are unwilling to negotiate, and are more
committed to the status quo than to growth. The arrival of crisis unmasks
family fragility and discloses multiple signs of dysfunction, although the family
may be aware of only one overriding complaint and look for help solely in that
area. This complaint then becomes the presenting problem brought to the
practitioner. An experienced practitioner will realize that the most conspicuous
problem represents only one aspect of a process perpetuated by the
relationships, behaviors, and attitudes used when the family was operating in a
state of equilibrium.
Even in brief crisis intervention, a comprehensive family assessment should
precede planning and implementing. Family members may insist that only
symptoms of the presenting problem should receive attention, but assessment
must include family process as well as family symptomatology. Following the
assessment, a practitioner must determine
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single, suffering unit (Giacquinta, 1977). The imminence of crisis begins when
the disease is suspected and arrives with the diagnosis; stress within the family
increases as treatment and the side effects of antineoplastic therapy begin.
Every family member is fearful of what lies ahead and questions his or her
ability to endure the future. The patient fears pain, death, and losing control.
Family members fear being
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Here
Antecedent
Anticipated
and
past
future
now
Dimensions or Characteristics of
Individual Members
1. What members comprise the
nuclear family?
2. What members comprise the
families of origin?
3. Which member is the identified
patient or patients?
4. What signs of equilibrium or
disequilibrium are apparent in the
indentified patient?
5. What signs of equilibrium or
disequilibrium are apparent in other
members?
6. What signs of equilibrium or
disequilibrium are apparent in the
family system?
Dimensions or Characteristics of
Internal Family Communicaton
1. How does each family member
communicate and interact with other
members of the nuclear family?
2. How does each family member
communicate and interact with
members of the families of origin?
3. How are decisions made in the
family?
4. How is conflict handled in the
family?
5. Who is the socioemotional leader
in the family?
6. Is leadership invested in both
parents, one parent, or neither
parent?
7. Are family alliances based on
natural distinctions of age, gender,
and generational roles?
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Here
Antecedent
Anticipated
and
past
future
now
Socioeconomic Dimensions or
Characteristics of the Family
1. Are family and socioeconomic
resources sufficient for basic needs?
2. Is there harmony between
material resources and family
expectations?
3. Are the hopes and expectations
of family members realistic?
4. Are the hopes and expectations
of the family members unrealistic?
5. Are conditions present that are
likely to promote class
advancement?
6. Are conditions present that are
apt to promote class slippage?
7. Are external socioeconomic
resources available to the family?
8. Are external socioeconomic
resources acceptable to the family?
9. What are the prevailing
communication patterns in the
family?
Specific?
Consistent?
Ambiguous?
Tangential?
Contradictory?
Placating?
Blaming?
Confusing?
Dimensions or Characteristics of
External Family Communication
1. Are family boundaries open or
closed to external influence?
2. Is the family integrated into the
social mainstream?
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Here
Antecedent
Anticipated
and
past
future
now
3. Is the family isolated from the
social mainstream?
4. How does the family relate to
larger systems, such as school,
church, or community?
5. How do individual family
members relate to external
systems?
Psychological Dimensions or
Characteristics of the Family
1. Whose needs are being met in
the family?
2. Whose needs are being ignored in
the family?
3. Where is the locus of power in the
family?
4. Who is the task leader in the
family?
When she was unable to participate in peer group activities, Angela felt isolated.
Many mothers of her classmates worked outside the home, and Angela noted that
these girls seemed to have more freedom than she was
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allowed. She could not understand why her little brother was giving everybody so
much trouble. Mark had enjoyed school until his mother went to work, but now he
saw her job as a threat to his security. He hated the way Angela treated him, and
honestly felt too sick to go to school. Even though Mark's ''accidents" annoyed his
teacher and the other children teased him, Mark preferred this embarrassment to
staying in school all the time. His erratic attendance caused Mark's teacher to warn
the parents that the boy was not making satisfactory progress. No one in the family
informed the teacher that Mark's altered behavior coincided with his mother's return
to work outside the home. The family did not discuss Tony's business worries with
outsiders, nor had the parents told Angela that her mother's job was financially
important. The office manager where Marie worked was impatient about her
unreliability. Since the office manager was unaware of the family's financial
problems and of Mark's school phobia, she told Marie that her job was in jeopardy
unless things changed. Marie was an intelligent, competent secretary, but her boss
was under the impression that the job meant very little to Marie and therefore she
considered Marie irresponsible.
and sometimes Tony felt desperate. If his brothers or father had lived closer, Tony
might have confided in
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them. Most of the time, though, he was glad that there were no relatives around to
witness the family's predicament.
Critical Guidelines
Although Mark's school phobia was the presenting complaint, most of the problems
of the DeLuca family lay within the dimensions of internal communication. The
parents never shared their feelings or resolved their discrepant perceptions of family
obligations. Even though Marie DeLuca eagerly welcomed a chance to work outside
the home, her employment threatened her husband's self-image. Financial worries
were very real for the family, but both parents avoided the subject. In their wellintentioned zeal to protect their children, the parents had not told Angela or Mark
about the importance of their mother's job. Extra duties were imposed on Angela
without soliciting her understanding or rewarding her cooperation. In many ways
she was as puzzled as her little brother. Since she could not engage in reprisals
against her parents, she was as unpleasant as possible in her dealings with Mark.
Mark's school phobia produced a family crisis that brought the boy and his mother to
a child guidance clinic. A family dimensional assessment was used to clarify the
problem, which was actually one of deficient internal and external communication. It
was not only Mark, but all the other family members who were using primitive,
nonverbal communication techniques. Several meetings were arranged so that
parents and children could discuss the family's temporary financial problems. Poor
communication was due to the father's pride and to the overprotectiveness of both
parents. A short-term goal was set to improve verbal communication. In one family
meeting, Mark indicated that a boy in his class had become very unhappy when his
parents were recently divorced. Both of the divorcing parents had worked outside
the home, and Mark connected the two facts. When the boy was placed into his
father's custody. Mark leaped to the conclusion that working mothers did not keep
their little boys. The family communication avoidance patterns prevented Mark from
obtaining the reassurance he needed.
After meeting with all family members, the counselor met with the husband and
wife. In these meetings, the focus was less on the family crisis that Mark's school
phobia (presenting complaint) had created than on poor communication (family
process). The parents were advised to arrange with school personnel that Mark
would arrive late on the days he complained of feeling ill, but that he would not
spend the whole day at home with his mother. When Mark had an accident at
school, his mother would bring a change of clothing, but she would not take Mark
home with her. Mark's teacher and Marie's boss were to be told of the plan and their
cooperation was sought. Her parents were to give Angela recognition for taking
good care of Mark in the form of free time during weekends and the parents
expressing their appreciation.
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With the immediate problem eased, the parents became willing to admit their own
disagreement. The counselor pointed out that reticence between the couple was
contributing to the children's dysfunctional, imitative behavior. Fear of abandonment
was the cause of Mark's behavior, and inadequate communication among family
members had nourished this fear. Tony's pride and his traditional views of family
role enactment were interpreted as functional, except when he resorted to
controlling tactics that made Marie feel like one of the children.
Resolving Mark's school phobia was successful as a result of the meetings, and the
dimensions of internal and external family communication improved. No
characterological changes were produced in either Tony or Marie, but both proved
capable of some insight. Moreover, a state of trustfulness was established between
the family and a professional counselor as a result of Mark's improvement.
Subsequent issues in the family would find them more receptive to adaptive
problem solving.
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Individual Dimensions.
Ben and Dora were in their late forties. The children were Jim, Dave, Sara, George,
and Benjie, whose ages ranged from ten to eighteen years. Jim was a student at a
community college, Dave and Sara were in high school, George attended junior high
school, and Benjie was in elementary school. The children were bright and
attractive. When the children were younger, they enjoyed spending time in the
store, waiting on customers and putting stock away. In the evenings they would do
their homework upstairs while Dora and Ben worked in the store. Some years
earlier, when Ben was forty, a large crate had fallen on his foot, crushing it severely.
Because of his diabetes and because he returned to work too soon, an infection set
in, and Ben's leg was amputated just below the knee.
During Ben's convalescence, the family mobilized to keep the store open. The three
older children got up early to open the store, and arranged shifts after school to
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afternoons and evenings. The emergency period lasted six months, after which Ben
returned to work in the store.
stump. She suggested shortening their business hours, but this set Ben off on a
tirade against his lazy children and against Dora for spoiling them.
After their parents retired for the night, the older children would vent their guilty
feelings on one another and on the "damn" store, which they were tired of hearing
about. The two
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youngest boys would huddle near the television set, feeling miserable and resolving
inwardly never to be as selfish as their older brothers and sister.
Critical Guidelines
Despite the problems in the family, strong bonds of affection existed. Poor
communication patterns, existing among all the members, impaired the family
function. Ben wanted and needed help, but he never discussed his needs rationally.
Dora, who could not tolerate recriminations or quarrels, passively accepted the
behavior of her husband and children. The parents had not clearly requested the
children to work in the store for a specific number of hours, nor had they allocated
working hours equitably so that no one was seriously inconvenienced. It was
apparent that, as the children matured and the parents aged, old rules were
outgrown but new rules were never formulated.
Because of the obvious strengths in this family, a crisis approach proved effective.
Ben needed to realize that it was no longer necessary to work himself and Dora into
exhaustion. The first goal in the family meetings was to reduce the business hours
to some extent. Both parents and all the children were involved in these
negotiations. It was hard for Ben to agree to this reduc-
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tion, but eventually he became willing to participate. Ben's reward for reducing store
hours was a written commitment from the three older children that each would work
eight hours a week in the store. The younger boys agreed to each work four hours a
week. In addition, a paid helper would be employed on Saturdays, so that all the
children would be free on weekends.
Since schedule conflicts were bound to arise, the family was given the task of
solving a simulated problem. The role play resulted in the following procedures:
When a child could not work a designated time in the store, that child was
responsible for arranging a substitute. Whenever a sibling substituted, the time
given was a debt that must be repaid as soon as possible.
The right of each family member to engage in outside activities was acknowledged,
and individual priorities deserved respect. However, the hours promised to Ben
constituted a primary obligation that could not be avoided or changed without
preliminary discussion. Dora was not to be called upon to work extra hours in the
store to make up for the absence of a son or daughter. When dissatisfied with the
children, Ben was to deal directly with them, and not discharge his resentment on
Dora.
The brief family counseling sessions focused on the changing needs of every family
member. Communication patterns were encouraged in which messages were clearly
transmitted and rules were clearly stated. Change was presented as a universal
process, which could be handled constructively if communication lines were open
and direct. Many positive feelings existed in this family, but they were rarely
expressed. As a result, negativism and frustration characterized most family
interactions. Members were encouraged to demonstrate the pride and affection they
felt for each other, and to be less self-centered and withholding.
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after the loss of an ill parent (Masterman & Reams, 1988). Often, a referral to
a support group can make the difference between adaptive grief reactions and
prolonged depression (Sable, 1989).
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Summary
Even though crisis counseling is short term and addresses limited goals, it is
useful in helping marginal families facing a crisis of illness or loss. Marginal
families strive for adequate role enactment, but become dysfunctional when
demands outweigh the family's physical and psychological resources. These are
vulnerable families, whose urgent needs often go unrecognized. Unlike
disorganized families, where role enactment is inappropriate, marginal families
rarely come to the attention of organized sources of help. Whenever the total
resources of a family are limited and the demands on the family become
excessive, the result is disequilibrium and family crisis.
When a family member falls ill, that person is expected to fulfill the obligations
and exemptions that are considered part of being sick. The attributes of sick
role enactment, as Parsons conceptualized, have been widely accepted despite
some inconsistencies. Individuals who suffer psychiatric disorders enact the
sick role differently from persons suffering physical disorders. Those physical
disorders that are acute and curable adhere most closely to the Parsonsian
model. When a physical disorder is chronic or terminal, there are substantial
departures from the Parsons's formulation.
There are clinical obstacles in crisis work with families. The practitioner
engaged in crisis work must decide whether to confine intervention to the
presenting problem or to expand intervention to include modification of family
process. Even when family process is not given direct attention through
interventions, it is part of family assessment in crisis work. In working with
most families, a middle-of-the-road approach is advisable. Short-term goals can
be constructed that respond to the immediate problem, after which the family
may be receptive to more extensive measures.
Comprehensive assessment is required for families in crisis, even when
interventions are time limited. Applying the paradigm of family dimensions is an
excellent way of organizing family assessment data.
Even under the best circumstances, marginal families constitute a vulnerable
population. Group programs offered in the community may be more acceptable
to these families than programs that imply a deficiency or disability. Another
factor important to marginal families is the feeling that health care
professionals respect them. The concept of empowerment has been applied to
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11
Disorganized Families in Crisis: Child Abuse
Children begin by loving their parents; as they grow older they judge them; sometimes
they forgive them.
Oscar Wilde
Page 266
discovered chained to a bed, and the abusers could only be charged under
statutes forbidding cruelty to animals.
Definitions of child abuse change from one decade to another and from one
culture to another. For centuries, harsh treatment of children was justified on
religious and economic grounds. Patriarchal family systems enforced control
measures that relied upon severe physical punishment. Mutilation in the form
of castration, clitoridectomy, and scarring are still practiced in some societies.
These are ritualized rather than punitive practices, but they constitute abuse in
the broad sense of the term. Children have been mistreated in the workplace
throughout the world. They have been enslaved, recruited as forced laborers,
abandoned to starvation, sold into sexual bondage, and deliberately killed.
Child neglect and abuse has been acknowledged as social problems in the
United States only in recent years. Henry Kempe (1961) introduced the term
battered children syndrome and chaired a symposium on the issue at the
American Academy of Pediatrics. This well-attended meeting became the
impetus for wide public interest in child abuse as a national problem.
The true incidence of child neglect and abuse is greatly underestimated
because there is undoubted disparity between incidence rates and reported
cases. Statistics indicate that about three million children are abused every
year. Reports on the sexual abuse of children indicate that one-third to twofifths of such incidents involve other family members, and one of every twelve
involves a father or step-father (Kissel, 1986).
Child neglect and abuse ranges from indifference to a child's physical needs for
food, clothing, and shelter, to physical mistreatment resulting in severe injury
and sometimes death. Culp et al. (1991, p. 116) defined physical abuse as
"any physical injury inflicted on a child other than by accidental means." They
defined neglect as "failure to provide the proper or necessary support,
education required by law, medical, surgical, or any other care necessary for
the child's well being."
Mandated reporting of child neglect and abuse is required by all 50 states.
Certain professionals, such as medical and nursing personnel, social workers,
teachers, and counselors, must not only report any case of abuse, but they
also must report any suspicion of abuse. In addition to mandated reporting,
most states offer immunity from civil and criminal action to any person
reporting in good faith, even if the report proves to be erroneous. Some states
provide possible civil penalties against those who fail to report child neglect or
abuse. Although officialdom is committed to mandated reporting, there is
evidence of substantial underreporting. In their study, Hampton and
Newberger (1985) disclosed bias in the reporting of child abuse. In a national
sample they found that hospitals under-reported white families to child
protective agencies. Ninety-one percent of Hispanic and 74 percent of black
families were reported, compared to
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intervention.
Abusers' Traits
Many experts believe that abusing parents are recreating their own upbringing,
but Kaufman and Zigler (1987) examined the accuracy of this belief, citing
methodological deficiencies in various studies. Although a history of abuse is
more common among parents who mistreat their
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potentially abusive parent, (2) a relatively helpless child, (3) and a sudden or
ongoing life crisis.
For many reasons, single parents may be at risk for child abuse or neglect. The
mother may transfer her anger at her husband to a son, who then becomes
the object of mother's rage. Sometimes a parent's inadequacies or fantasies
are projected to a target child. A father may punish a son brutally for imagined
signs of weakness or effeminacy that the father
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fears in himself. A mother may project her own coping style by accusing her
four-year-old daughter of being seductive and manipulative. In families where
the children have different fathers, the alleged shortcomings of one father may
be attributed to his child so that the child is punished for the sins of that father
(Gelles, 1989).
Counseling Abusing Families
Professionals who can control their own emotional responses and realize that
helping the child includes helping the parents are more likely to be effective.
When all attention is directed to the unacceptable behavior of the parents and
no attention is paid to their human needs, the parents become defensive and
less open to change. Professionals must avoid emotionality when dealing with
abusive parents and should be reminded that the parents are probably
replicating the patterns of their own childhood because they have no other way
of interacting with their children. In general, abusive parents expect their
children to act like adults, and they establish unrealistic standards of behavior
for the child. Parents who beat or burn their children frequently recall similar
acts their own parents performed and point, with pride, to the efficiency of
such methods in teaching children a lesson.
Abusive parents become suspicious and guarded when professionals begin to
investigate suspected child abuse. Expressing concern for the parent as well as
the child is an intervention that helps reduce defensiveness and elicit the truth.
It is productive to acknowledge that parenting is a difficult task, especially
when superimposed on holding a job or maintaining a single-parent household.
Certain nonthreatening questions may be used advantageously in interviews
with parents suspected of child abuse:
Is there anyone available to help when your child is very demanding?
When you are disappointed with your child's behavior, how do you feel?
When your child cries or refuses to obey, what do you do?
Do the eating, sleeping, or toilet habits of your child upset you?
What is your first reaction when you become angry with your child?
Pregnancy and childbirth may be natural processes, but parenting is not.
Parenting is a behavior that must be learned, either through childhood
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not imply acceptance for abusive practices, but rather belief that the abusing
parent can alter maladaptive patterns with the help of skilled professionals.
Some interventions are more productive than others. Among the unproductive
interventions are the following:
Unproductive Interventions with Abusive Parents:
Criticizing, confronting, and castigating the parents.
Imposing personal values and standards.
Expecting immediate changes in the behavior of the parents.
Identifying either with the abused child or with the abusive parents.
Productive Interventions with Abusive Parents:
Discuss childrearing and child discipline in general.
Modifying unrealistic parental standards.
Cooperating with the parents rather than retaliating.
Tolerating anger the parents express.
Modeling and teaching good parenting behavior.
Consultation to reduce overinvolvement and validate progress.
It is extremely difficult for caregivers to monitor their personal reactions to child
abuse or neglect. Identifying with the child and having negative feelings
toward the abuser will inhibit establishing a therapeutic alliance. For this
reason, it may be inadvisable for the same counselor to work with the abused
child and the abusing parent, although a collaborative relationship is essential.
In some communities, interdisciplinary teams have been brought together to
help families in which actual or potential abuse has been discerned. One urban
prototype for child abuse prevention is organized around a nursery that admits
babies and children from homes that may be unsafe for them. The crisis
nursery accepts abused children and children who may not have been
mistreated, but whose parents verge on losing control.
For other parents who are undergoing stress but are struggling to function, a
day care facility for the children is available. Supportive and psychotherapeutic
group work is offered to parents whose children are in the crisis nursery or the
day care center. Community nurses and social workers make frequent home
visits that are an indispensable part of the crisis prevention program. A twentyfour-hour hotline is also available for families being served or needing to be
served by the staff.
Whenever possible, families are kept intact, and parents are encouraged to
seek help whenever family tensions increase. Caretakers involved in the crisis
program retain the right to take families to court and remove children from
homes when necessary. At the same time, interdisciplinary team members
function as spokespersons and advocates for the parents as
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well as the children. They coordinate support services, visit homes at night or
on weekends, offer referrals for marital counseling and alcohol or drug
rehabilitation, and make crucial decisions to remove children from homes or
allow them to return. Workers involved in effective child abuse programs move
beyond the point of regarding abusing parents as incorrigible. Most abusing
parents are neither psychotic, wholly unloving, nor unteachable. As products of
dysfunctional family systems, they must be included in preventive programs if
permanent foster care or institutionalization of the children is to be avoided
(Aber, 1981).
Working with child-abusing parents requires a multifactorial approach. An
abusive parent can often be helped by psychodynamic concepts that accept
the underlying dependency needs of the abuser and facilitate parental
movement through psychosocial developmental stages. Inherent in this
approach is building the trust between the parent and the care provider.
Psychotherapeutic individual therapy for an abusive parent is a valuable
adjunct to the comprehensive social and environmental measures the
interdisciplinary teams working collaboratively with the family use.
Group work with abusive parents can be useful, as the support network made
available through Parents Anonymous shows. For those parents who are
unwilling to affiliate with an organization clearly identified with child abuse,
alternative groups are available. Bowers (1986) suggested that groups
organized for abusing parents first allow ventilation for members' frustrations
and then move into the realities of child development and parenting. Issues
need not be restricted to current parenting problems but may include the
childhood experiences of the parents in their families of origin, their
interpersonal relationships, and their social milieu. Group work with abusive
parents should be augmented with interdisciplinary measures that ensure that
the children are protected and that the abusive practices do not continue.
Frequent contact with community nurses, social workers, pediatricians, and
protective agencies is not only therapeutic for parents, but maintains ongoing
family surveillance.
Some clinicians, who fear that reporting will impair the therapeutic alliance,
perceive the mandate to report any form of child abuse or neglect as a burden.
Harper and Irvin (1985) saw the mandate to report as a therapeutic tool that
cuts through denial and contributes to the task at hand. It is obvious that
being labeled abusers pushes parents into greater awareness of reality. The
counselor should establish a relationship with the family that combines
empathy with consistent limit setting. It is essential that all professionals and
paraprofessionals maintain similar attitudes and present a united front. The
following precepts in mandated reporting of child mistreatment, adapted from
Harper and Irvin (1985), should be followed in clinical dealings with abusing
families.
Page 273
to his insistence that she allow men to pay her for having sexual relations with
them, and she walked the streets looking for partners when other assignations were
unavailable. When Mona became pregnant with Betsy, Gus left, saying that
Page 274
he was not going to support any kid that might not be his. Mona was convinced that
Gus had fathered her child and she saw in Betsy many resemblances to Gus.
Mona's behavior to her daughters reflected her attitude toward their respective
fathers. Daisy was fed regularly, hugged, and rocked to sleep occasionally. With
Betsy, Mona behaved like another child rather than a mother. She yelled at Betsy
constantly, and slapped her often. When Betsy cried, Mona would pinch her arms or
legs to make her stop. Mona bought toys for both children, but Betsy's were placed
on a high shelf so that the child could only gaze longingly at them. Mona's
explanation was that she could not afford two sets of toys, that Betsy was such a
terror she would break everything and there would be no toys left for Daisy when
she was ready for them.
Once in a while Mona tried to hug Betsy, but the child pulled away. When Mona was
depressed or lonely she would turn to Betsy and ask, ''You do love your mommy,
don't you, honey?" Betsy would giggle nervously or else stare round-eyed and silent
at her mother. Mona would then lose her temper and berate and strike her unloving
child. When Mona completely lost control, she would drag Betsy across the room
and lock her in a closet. Betsy's frightened cries enraged her mother even more.
Mona would scream at Betsy not to wake the baby and threaten to throw Betsy off
the fire escape if her sister awakened. Eventually, Betsy would cry herself to sleep.
More often than not, Mona let the child go without supper and kept her in the closet
all night. In the morning, a remorseful Mona would unlock the closet, insist that
Betsy eat a big breakfast, and then put the bewildered child in bed in order to make
up for spending the night in the closet. Even though Betsy was not particularly
sleepy, she learned quickly that it was better to stay in bed, for the alternative was
another isolation period in the closet.
Betsy was a typical target child in many respects. Brighter and more active than her
sister, she made demands that her mother considered excessive. Moreover, the
treatment Mona received from Betsy's father left a residue of anger and hostility
that was displaced to Betsy. As a child, Mona received abuse from an alcoholic
father and an indifferent mother. She left school in the tenth grade to live with Gus,
and her knowledge of child development and child care was rudimentary and
distorted. Because Daisy was a calm, cuddly baby, Mona loved her and felt that the
child loved her in return. In contrast, her feelings about Betsy were conflicted. Mona
insisted on behavior that was inappropriate in terms of Betsy's age and
temperament. Mona expected both children to meet her deep needs for affection. In
addition, self-control, obedience, and maturity were expected of Betsy. Mona did not
understand that she wanted the impossible from her three year old. When the child
failed to conform or achieve, Mona interpreted this failure as "badness" and
punished Betsy wildly and irrationally. Because Betsy had a vitality that was not
easily quelled, Mona saw Betsy as the embodiment of the man who had mistreated
her. Since he was beyond her reach, she vented her anger on his child.
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Except for a few girlfriends, Mona led an isolated existence. It was a welfare worker
visiting the home who first became aware of the bruises and welts on Betsy's small
face and body. After the child pointed out the narrow closet as "Betsy's bed room,"
the worker began a systematic inquiry into Mona's mothering practices. The result
was a referral to the children's protective association, to a community health nurse,
and to a local mental health center for an evaluation of Mona.
Critical Guidelines
After Mona was evaluated at the mental health clinic and no diagnosable psychiatric
disorder found, she was assigned to a psychiatric nurse clinician for help with
problems of immaturity, impulse control, and poor self-esteem. The visitor from the
children's protection association considered the family to be at risk. Ongoing
supervision was advised and a protective worker began to visit the household
regularly. The community health nurse used her concern for the health of the
children in order to win Mona's trust. Once she was accepted in the home, the nurse
began to teach Mona what to expect from her children as they moved from one
stage of growth to the next. The welfare worker functioned as case coordinator and
arranged several meetings at which all the professionals involved with the family
met together.
Discussion at the first meeting dealt with the possibility of removing Betsy and
perhaps Daisy from the household. Because there was agreement that removing the
children would probably cause Mona to have a replacement child or children, the
care providers considered how to make the home a safe place for the children. The
multiple problems in the family were apparent to all the care providers, but their
emphasis differed according to their discipline.
Problems the Community Health Nurse Identified:
Mona had no understanding of the developmental capacities and limitations of
preschool children. An essential goal was to teach her about normal growth and
development. In addition, Mona needed to acquire some understanding of
temperamental differences among children, especially between Betsy and Daisy.
Since Daisy would inevitably become a mobile toddler, knowledge of normal
behavioral patterns would prevent this child from sharing her sister's fate.
Although the children had different fathers, both belonged to Mona. Her fondness for
Daisy was obvious, but she needed to accept Betsy as a child equally deserving of
care. The community health nurse began to relabel Betsy's behavior so that Mona
could appreciate the precocity and intelligence that now provoked her anger. Some
similarities between Mona and Betsy were evident. These resemblances could be
pointed out to discount Betsy's paternity and foster closeness between mother and
daughter.
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Problems the Protective Worker Identified:
Mona had public assistance support because the whereabouts of her husband was
unknown. Although Mona managed her money fairly well, she could afford few
luxuries. For example, she could not save enough money to cover the security
deposit necessary to install a telephone. This meant that she was isolated in her
small apartment, especially during the winter when she and her girlfriends were
unable to visit with their children. The protective worker believed that a telephone
was essential so that Mona could maintain communication with the outside world,
and prevailed on the welfare worker to arrange telephone service.
Although the protective worker was unsure about leaving Betsy in her mother's care,
it was thought that with close supervision Betsy might be allowed to remain.
Arrangements were made for Betsy to attend day care at the home of a welfareapproved mother. Since other preschoolers would be present, the socialization
would be beneficial for Betsy. The day care mother would also be in a position to
observe any evidence of abuse and monitor Betsy's progress.
Problems the Psychiatric Clinician Identified:
Mona was deficient not only in her knowledge of child development, but also in her
early experience with a mother figure. She described her own mother as cold and
neglectful rather than abusive. According to Mona, her mother never praised or
punished, but allowed her children to fend for themselves. A succession of men lived
with Mona's mother after her natural father died. Some of these men were violent
with Mona and her three brothers. Betsy's father had been living with Mona's mother
when his sexual relationship with Mona began.
Feelings of competition and rivalry characterized the relationship between Mona and
her mother. Indeed there was reason to suspect that Mona had entered the
relationship with Betsy's father primarily to annoy her mother. Therefore, Betsy
represented a transgression against the mother whose love Mona still wanted. Since
many of Betsy's personality traits were like Mona's, there was a tendency for Mona
to project her old rivalrous feelings toward her mother onto Betsy. Thus, she saw in
Betsy a rival rather than a tiny girl. These unconscious conflicts were reinforced
when Mona's pregnancy caused Gus to abandon her.
The attention of the community health nurse and the protective worker was
appropriately directly to the children. However, Mona had suffered nurturing deficits
that prevented her from being a good mother. So far, her care of Daisy was
exemplary, but Mona was likely to become abusive toward both her children unless
her own psychological needs were met. Mona needed to be shown how to be tender
and caring with her children, but she first had to experience tenderness. The
psychiatric clinician proposed that Mona be permitted a period of dependency so as
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Besides meeting Mona's dependency needs in their therapeutic sessions, the
psychiatric clinician used a behavior modification approach. When Betsy's behavior
aroused anger, Mona was told to leave the room immediately without responding to
the behavior. She was to call one of her care providers on the phone and discuss
what had happened. If none was available, Mona was to leave a message and then
call the twenty-four-hour crisis line to discuss the situation and plan her response to
Betsy. Only then would she begin to deal with Betsy's problematic behavior.
A prompt referral to Parents Anonymous, a self-help group formed to prevent child
abuse, was recommended for Mona, and arrangements were made for members of
the group to take Mona to the meetings.
The plan for the family was multifaceted and required collaborating with the
representatives of several agencies. Three levels of prevention were operating as
the plan for Mona was made. There was primary prevention of abuse toward Daisy
as she moved toward the active negativism of the average toddler. Betsy was the
beneficiary of interventions in the category of secondary prevention. Therapeutic
modification of Mona's attitudes toward herself and alteration of her behaviors
toward the children constituted a form of tertiary prevention.
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takes place in many intact families where both natural parents are present in
the home. Lower socioeconomic class has been linked to sexual abuse, but
other data indicate that, unlike physical abuse, the sexual abuse of children is
not connected to class. Alcohol abuse is sometimes thought to be a factor, but
a study by the American Humane Association showed that sexual abusers of
children had consumed low amounts of alcohol (Parker & Parker, 1986).
Despite research contradictions, there is agreement on some points. In
reviewing the literature in the field, Parker and Parker (1986) found that:
Perpetrators are overwhelmingly male and victims are female.
Deprivation in the perpetrator's family of origin has induced low self-esteem
and social inadequacy.
Perpetrators are not mentally retarded, nor characterized by psycho-pathology
or criminality.
Sexual abuse of children in the family is rarely accompanied by physical abuse.
Stepfathers or other father surrogates, such as the mother's "boyfriend," are
overrepresented among abusers.
Female children living with stepfathers are at high risk for sexual abuse. In
describing the antecedents of abuse, Finkelhor (1980) wrote that:
One of the strongest risk factors, having a stepfather, more than doubled a child's
vulnerability. Moreover, this risk factor remained the strongest correlate of
victimization, even when all other variables were statistically controlled ...
Apparently there is substance to the notion that stepfathers are more sexually
predatory toward their daughters than are fathers (p. 269).
The same investigator found that stepfathers who were not present in the
home during a daughter's early years were more prone to sexual abuse; those
present in the home in a daughter's early years were no more likely than a
biological father to engage in sexual abuse of the girl. Evidently, physical and
psychological distance between a girl and a father or stepfather produces a low
threshold stimulus for sexual arousal. The combination of a man's psychosocial
deficits and his lack of involvement in the early years of a daughter's life seems
to increase the probability of sexual abuse. For men who cannot meet the
demands of a mature sexual relationship, a child becomes a perfect object of
gratification. Incest between an adult male and a child resembles other
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somewhat less exploitive of others. Consistent with later findings, Storr (1964,
p. 101) described,
It is not from superfluity of lust, but rather because of a timid inability to make
contact with contemporaries that a man generally finds that children form the focus
of sexual interest.
A father who sexually abuses a daughter seldom needs to use physical force
because of the helplessness of the girl and the strength of the emotional bond.
Added to the father's power as provider and authority figure is the threat of
reprisal or a family breakup unless she submits. The feared punishment need
not be specific, for the greatest fear of children is that their parents will
withhold love and approval if the child disobeys or rebels. It is usually the
threatened loss of love that persuades children into colluding in their own
sexual victimization.
If the incestuous relationship brings attention or pleasure to the victim, there
may be some gratification. However, many young girls are psychologically
traumatized, not gratified as victims, and also experience great physical pain
and damage. Physical, emotional, and behavioral consequences of child sexual
abuse, adapted from Janosik and Davies (1989), are summarized as follows:
Physical Consequences:
Rectal fissures and rectal sphincter damage
Anal and vaginal lacerations
Gonorrheal infections of genitals, tonsils, larynx, and pharynx
Pain and physical discomfort
Emotional Consequences:
Sense of betrayal
Feelings of guilt and shame
Need for secrecy and concealment
Loss of trust in significant others
Anger toward both parents and generalized hostility
Feelings of helplessness and powerlessness
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male and female victims had an equally high likelihood of reactive suicide
attempts. One hypothesis, as yet unproven, is that sexual abuse may be more
traumatic for males, since less severe abuse of males is associated with residual
effects equal to that of females. It has also been suggested that male victims
of sexual abuse are more inclined to act out their trauma through violence
toward others, whereas females tend to
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the insult to herself than the injuries her daughters suffered. "This whole mess
makes me feel awful," she said. "I must not be enough of a woman to satisfy my
husband." She was mollified when the psychiatrist responded, "Perhaps you are too
much of a woman for your husband right now. Dealing with grown-up women may
be part of his problem."
Marie and Caroline looked scared and uncomfortable. They clung to each other and
Marie said softly that everything was her fault, not her father's. The psychiatrist and
the pediatric nurse, who was sitting with the girls, went to some lengths to reassure
the girls that they had not been at fault in any way.
Critical Guidelines
After reporting the incident to the police and notifying the Children's Protective
Association, the staff, the pediatrician, the consulting psychiatrist, and the pediatric
nurse made the following decisions. The children were not to be removed from the
home provided the grandmother remained with the family until treatment was
instituted. Because this was a police matter, the recommendations were mandatory
for the family.
Psychological evaluation and followup for Marie and Caroline.
Psychiatric evaluation and individual psychotherapy for Jeff.
Marital counseling for the couple.
Long-term supervision by the Children's Protective Association.
Crisis intervention for the entire family unit.
Family crisis intervention involved every member, including the grandmother, who
wielded considerable influence. A nurse and a social worker, functioning as a family
crisis team, provided this aspect of treatment. At the start, family feelings were
high. Jeff was guilty and anxious, Vera was depressed and self-engrossed, and the
grandmother was angry with her daughter for not knowing what was happening.
The two girls were worried because there was so much trouble in the family, and
the boys were bewildered by events.
In order to reduce tension and recrimination in the family, the crisis team chose to
use role theory to explain family disorganization. This tactic enabled the crisis
workers to point out that the family was in trouble because role enactment was
inappropriate, particularly the role performance of the parents. Vera was told that it
was part of her role as mother to get up and help get the children ready for school.
Jeff was told that his role performance was the most destructive of all. His role in
the family was to be a husband to Vera and a father to his children. This role did not
include making love to his daughters or exploiting them in any way. When marital
and sibling roles in the family were performed properly, every member was
protected. When role enactment was selfish and exploitive, every member suffered
and the family became disorganized and dysfunctional.
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Using role theory enabled family members to understand and accept the
interventions of the crisis workers, thereby reinforcing the idea that role confusion
had created a great deal of pain for this family. Jeff remained the victimizer, but the
family problem was defined and clarified in role theory terms, which invited
everyone to change family behavior. Crisis intervention merely prepared family
members for the comprehensive treatment that lay ahead. During the time-limited
contract, the crisis team taught the family that behavior that is not role appropriate
threatens the rights of all family members and creates chaos in the system. With
this preparation, the family members were more amenable to long-term therapy.
Summary
Battered children, like battered women, are all too common in contemporary
life. The intergenerational transmission of family violence and respect for
parental rights have operated to victimize countless children. Since children
cannot extricate themselves from abusive situations, the responsibility of
professionals to report suspected abuse is ethically and legally mandatory.
Preventive programs for families at risk have been instituted with significant
results. Educating parents about child development and correcting the
nurturing deficits of abusive parents are tandem approaches that have been
successful in many instances. Support groups, such as Parents Anonymous, are
widely used by parents who need help with impulse control and related
childrearing problems.
Sexual molestation of children occurs in disorganized families in which role
enactment is blatantly inappropriate. The crisis that follows the discovery of an
incestuous relationship affects every family member. Psychological evaluation is
indicated for the molesting adult and the molested child. Following evaluation,
individual counseling is needed for the offender and often for the child. If the
parents are motivated to keep the family intact, conjoint family therapy, in
addition to marital and individual therapy, is necessary. Since incest
demonstrates abdication of appropriate role enactment, the use of role theory
early in treatment reduces anger, fear, and recrimination in the family
members who are not the principals, but who have become aware of the
incestuous relationship. The decision to remove the victim or the aggressor
from the home is best made on an individual basis, but ongoing supervision of
the family and the involvement of various voluntary and official agencies must
be maintained over time.
References
Page 287
Bowers, J.E. "Group Work with Couples and Families." In Life Cycle Group Work
in Nursing, edited by E. Janosik and L. Phipps. Boston: Jones and Bartlett,
1986.
Briere, J., D. Evans, M. Runtz, and T. Wall. "Symptomatology in Men Molested
as Children: A Comparison Study." American Journal of Orthopsychiatry
58(1988): 447-461.
Culp, R.E., V. Little, D. Letts, and H. Lawrence. "Maltreated Children's Self
Concept: Effects of a Comprehensive Treatment Program." American Journal of
Orthopsychiatry 61(1991): 114-121.
deMause, L. History of Childhood. New York: Harper & Row, 1974.
Finkelhor, D. "Risk Factors in Sexual Victimization of Children." Child Abuse and
Neglect 4(1980): 265-273.
Fontana, V. "Children Maltreatment and Battered Child Syndromes." In
Comprehensive Textbook of Psychiatry, 4th ed., edited by H.I. Kaplan and B.J.
Sadock. Baltimore: Williams & Wilkins, 1985.
Gelles, R.J. "Child Abuse and Violence in Single Parent Families: Parent
Absence and Economic Deprivation." American Journal of Orthopsychiatry
59(1989): 492-501.
Hampton, R., and E. Newberger. "Child Abuse Incidence and Reporting by
Hospitals: Significance of Severity, Class, and Race." American Journal of Public
Health 75(1985): 56-60.
Harper, G., and E. Irvin. "Alliance Formation with Parents: Limit Setting and
the Effect of Mandated Reporting." American Journal of Orthopsychiatry
55(1985): 550-560.
Hunter, R., and N. Kilstrom. "Breaking the Cycle in Abusive Families." American
Journal of Psychiatry 136(1979): 1320-1322.
Janosik, E.H., and J.L. Davies. "Situational Alterations: The Crises of Suicide
and Violence." In Psychiatric Mental Health Nursing, 2nd ed., Boston: Jones
and Bartlett, 1989.
Kaufman, J., and E. Zigler. "Do Abused Children Become Abusive Parents?"
American Journal of Orthopsychiatry 57(1987): 186-192.
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12
Disorganized Families in Crisis Spouse Abuse
If men and women are to understand each other, to enter into each other's nature with
mutual sympathy, and to become capable of genuine comradeship, the foundation
must be laid in youth.
Havelock Ellis
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actions, they soon learn that their voluntary behavior has no way of controlling
what happens to them. Therefore, they learn to be helpless and their survival
instincts are extinguished.
The organized movement against wife beating began in England in 1971 when
a woman named Erin Pizzey opened a modest home where local women and
their children could flee from violent husbands and fathers. Within a few years,
a network of such refuges was organized in the United Kingdom, and a
parliamentary investigation of domestic violence was instituted. A group calling
itself Women's Advocates, Inc., began a telephone information and referral
service in St. Paul, Minnesota, in 1972, and two years later opened a shelter
for battered women. About the same time systematic research on violence in
the home began to appear in professional journals. In 1976, the National
Organization for Women made available to the public a landmark publication
entitled Battered Wives.
Many studies show that family violence in the form of wife beating transcends
ethnic and social groups. One study of women in a shelter for battered women
found that the population was 62 percent white, 13 percent Chicano, 3
percent Asian, and 2 percent other. The abusing husbands of these women
represented almost every profession and occupation. It is highly likely that
protective and law enforcement agencies noticed the families at the lower-end
of the social scale more often. When upper- or middle-class husbands abuse
their wives, the behavior is hidden from public view because wives are too
ashamed to tell others (DeLorto & LaViolette, 1980).
Until the advent of the women's movement, responsibility for men battering
women did not altogether focus on the men. Instead, research centered on
understanding why men beat women and why women continue to stay with
men who beat them. The problem was intellectualized and conceptualized in
various ways. Instead of emphasizing choice and responsibility on the men's
part, researchers viewed violence as a family problem and a social problem.
This allowed responsibility to be allocated to both husband and wife, and to
blame adverse social forces that permitted men to act violently toward women.
Lamb (1991, p. 250) stated that "language both reflects and shapes our
understanding." She calls for a new linguistic style that does not diffuse the
responsibility for beating women. She also dismisses suggestions that men
behave violently toward women because they witnessed or suffered abuse from
their fathers, and discounts cultural standards that equate manliness with wife
beating. Family counseling is rooted in systems theory, which states that any
element of a system is related to and influenced by other elements within the
system. What Lamb states is that apparent collusion in a family may be the
result of coercion and intimidation. When an abusing husband's violence
toward his wife is interpreted only as the
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1977):
Controller. This man uses the partner as an object that he can control.
Defender. This man mingles hate and love; he depends on his partner to
accept and forgive him.
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Validator (approval seeker). This man is subject to self-doubt; he looks for ways
to reinforce his self-image as a man.
Incorporator. This man sees no separateness between himself and his partner;
he sees the partner as an extension of himself.
The typology that Elbow (1977) formulated has interesting implications. The
four personality patterns of abusers are characterized by specific actions and
behaviors that can be identified. The controller gets his way by persuasion,
threats, or use of force. People are important to him only in terms of what they
can do for him; they are seen as objects and there is no emotional reciprocity.
Violence occurs when the controller feels unable to dominate the wife. He
opposes ending the relationship because of his anxiety about losing control of
his wife, who is considered a possession. Granting her any autonomy is
equated with her controlling him.
The defender is not afraid of being controlled, but of being harmed. He is able
to feel strong only if his mate continues to cling to and depend on him.
Because he anticipates that his mate may punish him for being sexual and
aggressive, he believes that he must render her powerless so that he will not
be vulnerable to attack from her.
The validator has high expectations of himself. His self-esteem is contingent on
the acceptance and approval of others. Since his self-esteem is low, he expects
rejection and behaves in a manner that elicits rejection from others. The
prospect of losing his mate is extremely threatening, for this loss would confirm
his low regard for himself. He tries to avoid the loss of his mate through
intimidation, followed by remorse.
The incorporator is desperate because he cannot experience himself as a whole
person without incorporating his mate. Possession and incorporation of the
mate permits a degree of self-esteem, fear of losing her leads to ego
deterioration and self-doubt.
Some investigators have proposed a dichotomy of batterers, many of whom are
violent only at home and many who are violent both at home and outside the
home. The latter group engage in more severe violence and are more likely to
abuse alcohol. Men who are violent only within the home are more dependent
and more remorseful after being abusive (Shields et al., 1988; Brisson, 1983).
Men who are aggressive at home and outside the home are less inclined to
accept help and are more traditional in their ideas of what women should be.
To summarize, there is consensual evidence that there are two major types of
batterers, the dependent abuser and the dominating abuser. It is the
dominant abuser who seems to have more antisocial traits and engages in the
most severe forms of violence.
In a carefully designed research study, Saunders (1992) presented a typology
that differentiated three groups of men who batter women.
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Type 1:
Family-only batterers. These men reported lower levels of anger, depression,
and jealousy; they also reported higher values placed on social desirability.
Their violence was alcohol-related about half the time.
Type 2:
Generalized batterers. These men were the most likely to be violent inside and
outside the home; many suffered abuse as children, yet they reported low
levels of anger or depression. Their attitudes on sex role enactment were very
rigid. Their reports of a high use of alcohol and severe battering were reflected
in frequent arrests for drunk driving and for violent behavior.
Type 3:
Emotionally volatile batterers. These men were violent less often than the other
types, but were the most abusive psychologically. They were least satisfied in
their relationship with their partner. Their use of alcohol was less than that of
types 1 and 2. They tended to be the least defensive and the most accepting
of treatment.
An alternative explanation of this typology and others is that types or
categories of batterers represent different phases of the abuser's behavior.
Neidig et al. (1986) noted that most batterers "explode" into violent behavior.
Over time they realize that negative consequences rarely follow the explosion,
and they soon learn to employ violence as a means of controlling or coercing
their wives. The work of Walker (1984) showed that batterers showed "loving
contrition" after the first violent episodes, but with time the remorse
disappeared.
Treatment Based on Typology
The family-only abuser (type 1) is probably most responsive to intervention. He
can profit from assertiveness training, which helps him to express negative
emotions verbally. Batterers of this type are suitable candidates for marital
counseling, if both partners are willing to participate.
The man who is globally aggressive is type 2. A generally violent batterer
usually needs help in dealing with his memories of childhood abuse and in
dealing with his alcohol abuse. Cognitive restructuring can help him modify his
rigid ideas about sex role performance. Emotional exploration will put him in
touch with his feelings. Once he is able to recognize what he is feeling, work
on communication and impulse control can be undertaken. The batterer who
demonstrates generalized aggressiveness requires more than short-term, crisislimited intervention.
The emotionally volatile batterer (type 3) needs help in dealing with inner
turmoil without resorting to violence. He needs a cognitive approach that will
help him realize the destructive consequences of pro-
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longed psychological abuse of his partner. Cognitive restructuring will help with
impulse control and with learning to express emotions in more constructive
ways.
Alcohol and Violence
A significant influence in the manifold disturbances present in disorganized
families is excessive drinking by one or more members. Alcoholism is not only a
problem in itself, but complicates other crises in disorganized families, notably
spouse abuse and child abuse. Therefore, in such families, alcoholism may be
considered a crisis in its own right and a factor intensifying recurring crises of
family violence.
Three competing theoretical positions have been proposed to explain the
relationship between alcohol and aggression, particularly interpersonal
aggression. The first of these is predicated on the assumption that alcohol
affects aggressive behavior by the "energizing" influence of alcohol on general
activity level and aggressive fantasies. Another explanation is that alcohol does
not directly elicit aggression, but instead reduces inhibition and facilitates
expression of aggression by reducing fear of the social and physical
consequences of aggression. A third explanation of the relationship between
alcohol ingestion and aggression is that it is mediated by a psychological
acceptance set regarding the behavioral effects of alcohol consumption based
upon the popular tendency to attribute anti-social acts to the alcohol rather
than the alcoholic. One reward of heavy drinking is that it offers an acceptable
excuse for engaging in aggressive behavior without suffering great social
disapproval.
If the connection between alcohol and violence is based on reduced inhibition
via physiological channels, violence would presumably be greater among
individuals who drink most often. However, the most severe alcoholics seemed
to be anaesthetized rather than uninhibited, using alcohol to erase a world too
painful to contemplate. Persons who were inebriated from time to time were
more likely to use alcohol to engage in behaviors otherwise unacceptable to
themselves or others.
Even though there is an association between alcohol and violence, many
researchers are not sure that alcohol is a cause of wife beating. It is unclear
whether people become violent because they are drunk or get drunk to obtain
implicit freedom to be violent. Adding to the ambiguity is the fact that violence
often occurs in families who abstain from alcohol because of religious or other
convictions (Helfer & Kempe, 1976). Whatever the sequence, the need for
clinical intervention is obvious.
According to Hanks and Rosenbaum (1977), women who continue to live with
violent, alcoholic men seem to come from three types of family structures:
subtly controlling mother, figurehead father; submis-
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sive mother, dictatorial father; and disturbed mother, multiple fathers. Most of
the women professed warm feelings toward their parents and saw relationships
with their original families as excellent. They were sympathetic toward their
husbands, rarely sought help, and were overprotective of their children. The
investigators concluded that involvement with a violent, drinking man was
psychologically necessary to these women, regardless of the family structure of
their original family. It was thought that violence made the women feel
superior and needed when they rescued their husbands. The interactional
pattern gave meaning to their otherwise directionless lives.
Theoretical Explanations
Intrapsychic Formulations
Traditional explanations of wife beating have relied on Freud's concepts of
feminine masochism. In this formulation, the masochistic woman is described
as wishing to be treated like a helpless, dependent, naughty child. For the
masochist it is the suffering that is important, not the person who imposes
punishment. The maintenance of suffering is essential because punishment
relieves feelings of guilt. Freud (1959) saw this self-destructive behavior as a
result of failure to resolve the oedipal conflict. The female child is competitive
with her mother, but fears loss of the mother's love. In order to renounce the
father, the girl unconsciously provokes his aggression. This causes her to
forsake the male and mitigates the guilt associated with her earlier desires for
the father. This paradigm implies that women submit because of unconscious
beliefs that they deserve to suffer.
Shainness (1979) presented masochism as a process that involves certain
sociocultural features. Violent men tend to use violence as an ego-enhancing
mechanism because their repertoire of nonviolent behavior is limited. Often this
is the type of man to whom masochistic women are attracted. In this
explanation, masochism is not considered an instinct subject to libidinous
forces, but a behavior that developmental and cultural events influence.
Masochistic women have experienced and incorporated significant persons who
were harsh or cruel. Other factors, such as superior masculine strength and
lack of control over their reproductive processes, reinforce the submissiveness
of women. Thus, the tacit acceptance of abuse by women is a social and
biological heritage causing them to act in ways that perpetuate abuse.
In violent families, attacking others may deflect anger toward the self. Men
who feel inadequate or frustrated displace their negative feelings on their wives
and children. A vicious cycle of disappointment and resentment activates
feelings of guilt in some women, which are reduced
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when they are beaten. This welter of confusing feelings leads to more anger in
the women and ultimately to more beatings. Furthermore, the violent behavior
defends the male from dependency urges to merge with, surrender, or submit
to the female.
Sociological Formulations
The social organization of family life that contributes to intimacy also
predisposes to a high rate of violence, despite the image of the family as a
place of love and gentleness. Age and gender discrepancies, conflicting
activities and interests, and role dissonance and inflexibility are only a few of
the variables that add to family tension. Another important variable is the
violence of the society in which contemporary families are imbedded. There is
evidence of a circular pattern in which violence generated within families leads
to a violent society. At the same time, a society that accepts violence in public
spheres of life aggravates violent tendencies within families. In some segments
of society, violent behaviors may be legitimized and regarded as appropriate
responses.
Pursuit of rewards and avoidance of punishment guide human behavior and
interaction. Violence within a family will continue until the costs of violence
outweigh the rewards, and norms surrounding violence undergo change. There
are no strong indications that this process of change has begun.
Stressful life experiences are associated with assault between husbands and
wives; people under the least stress have the lowest assault rates. Men under
stress are more likely to assault their wives if the marriage is not important to
them or if they believe that a husband should be the dominant member of the
marital dyad. Exploring status relationships in cases of spouse abuse showed
that status inconsistency and status incompatibility were associated with risk of
psychological abuse, greater risk of physical abuse, and still greater risk of lifethreatening violence. Status inconsistency was characterized by occupational
underachievement of the husband, while status incompatibility was
characterized by the higher occupational achievement of the wife.
Interestingly, status inconsistency in the form of occupational overachievement
by the husband seemed to be a safeguard against outbreaks of violence
(Hornung et al., 1980).
The Feminist Formulation
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cast in the roles of victims. They are taught from birth that marriage and
motherhood represent fulfillment. To reach this goal, women must be feminine,
permissive, and submissive, submerging their inclinations to be free and
assertive. The patriarchal family structure legitimizes the inequality of the
sexes. If women assert themselves, they are abused for their temerity. If they
remain passive, they still provoke the
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Children who witness spouse abuse may be affected in diverse ways. Bandura
(1986) noted that children and young adults were inclined to identify with
aggressors, and clinical observation supports the statement that male children
of battered women often behave aggressively toward the mother. The
assumption is that the father provides a role model of violence for the sons,
while the mother provides a role model of ineffectuality for the daughters.
One reason that battered women give for not seeking help is that their
husbands are likely to retaliate. Retaliation may occur at times, but a study of
New York City programs for battered women indicated that they were less likely
to be victimized if they sought help (Barden, 1982). In this three-year study,
over one hundred abused wives who had received assistance from voluntary
and official agencies were interviewed. The investigators found that most
husbands who had been arrested or served an order of protection were unlikely
to continue their abuse, even when the wives did not follow through on legal
action. Clinicians working with battered women can truthfully assert that filing
complaints is helpful, even when women drop the charges rather than see their
husbands imprisoned. The report stated that 47 percent of the women said
that they were not beaten again once charges were filed. One woman noted
that reporting her husband to the police convinced him that any future
violence would bring reprisals.
The most effective form of assistance for battered women in the study was
crisis counseling, even though this form of aid did not directly reduce violence.
Crisis counseling helped the women explore their options, provided support,
and promoted decision making. Whether offered through hot lines, shelters, or
consciousness-raising centers, crisis counseling was considered to be very
helpful. About one-third of the women obtained professional individual
counseling in addition to crisis intervention; one-fifth of the group found this
counseling helpful.
Violent Wives
Although it is posited that there is little difference in the overall rates of
violence that husbands and wives enact, men tend to escalate levels of
violence, and most of the violence from wives constitutes self-defense. In
examining police calls for "domestic disturbances," there is little support for a
battered husband syndrome (Lamb, 1991). Generally, it was the women who
were found battered in these incidents, and in most domestic disturbances, the
men inflicted harm. The existence of a kin network system may act as a
deterrent to violence and also may play a decisive part in determining the
intensity and direction of family violence.
Family violence accounts for one-quarter of all homicides in the United States,
according to Federal Bureau of Investigation (FBI) Uniform
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had a sadistic component. Frieze (1983) studied wife rape in a group of 137
battered wives; one-third of these women reported being raped by their
husbands and two-thirds reported being "pressured" into having sexual
relations. Pressuring was characterized by threats of violence unless the wife
submitted. In this study, the raped and battered women demonstrated more
extreme reactions than did women who had been battered but not raped
(Frieze, 1983). Reactions of wives
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who suffered marital rape included outrage, fear, depression, anger, shame,
self-blame, pervasive sadness, and unhappiness. The intimate aspect of marital
rape makes disclosure difficult.
Alcohol seems to play a significant role in the perpetration of wife rape.
Finkelhor and Yilo (1985) found that out of forty-seven women in their sample,
70 percent stated that their husband had been drinking before an episode of
forced intercourse. In her study, Frieze (1983) found that 63 percent battered
women's spouses were either sometimes, usually, or always drinking during
violent episodes. Weingourt (1985, 1990) stated that the mental health
community has overlooked the marital rape issue. She also alleges that women
tend not to report marital rape or forced intercourse unless sensitive
questioning concerning the issue was encouraged.
The physical coercion that husbands inflicted included pinning or arm twisting,
hitting, slapping, and choking. Some women experienced no physical abuse
other than incidents of rape, many of which were accompanied by threats of
force. These wives emphasized their global feelings of shame and
worthlessness, anxiety, helplessness, and depression. Women who, were raped
but not battered were more likely to remain in the marriage, but their
psychological reactions were remarkably like those of women who were
battered and raped. Many battered women are reluctant to publicly admit the
abuse, and women subjected to marital rape are even more reluctant. Since
wife rape is one of the most damaging forms of abuse that husbands inflict,
the assessment of battered women should consider this possibility. Weingourt
(1990) declared that wife rape is a factor in the lives of many clinically
depressed, anxious women in the absence of overt battering. Marital rape is a
complex, hidden problem. More research is needed to discover the parameters
of the problem. More clinical attention is needed so that reticent women are
encouraged to disclose the existence and extent of this form of abuse.
Counseling Battered Women
For battered women crisis does not exist only in the abuse itself, but in the
turmoil that surrounds the decision to stay with the husbands or separate.
Unlike the child who is abused, the battered wife who does not leave her
husband, or who leaves and returns, does not receive much sympathy from the
public or even from caregivers. The suffering of many battered women is
unreported because the women have no hope of rescue. When a woman does
leave the abusing husband, she needs to be convinced that she is a worthwhile
person, and that responsibility for the abuse is the husband's, not hers. The
ambivalence and indecision of battered women is reflected in their pattern of
repeated reconciliations with the husbands, most of which turn out
disastrously.
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the presence of current stressors are among the early indicators of family
violence. Premarital counseling and prenatal counseling can be used to help
couples compare their expectations of marriage and parenthood, and perhaps
circumvent certain problems. Genetic counseling is an aspect of primary
prevention that receives less attention than it deserves. Exploring the risks and
difficulties attendant on bringing a congenitally damaged child into the world
can reduce the introduction of additional stress into the family system.
Secondary prevention can be equated with crisis intervention for the violent
family or any members thereof. The battered woman is encouraged to look at
her marriage and decide whether to separate, even temporarily. Within the
crisis framework, the woman's readiness for change can be noted, and she can
observe adaptive behaviors that other women have modeled in dealing with
similar problems.
Shelters for battered women are now available in most localities, and group
work is usually the basis of therapeutic programs at shelters. Group work with
battered women provides a support system in which the women realize,
perhaps for the first time, that they are not unique in their predicament.
Workers in the shelters are excellent resource persons to help with such
problems as child support, protection orders, housing, or vocational guidance.
Groups organized for battered wives provide a support system by which the
woman can, perhaps for the first time, realize that she is not alone. She
realizes that not only do many women share her problem, but some of them
have found the courage to separate from the abuser and begin new lives. She
feels less isolated as she begins to share her experiences with understanding
listeners. Within the group network, she learns how other women have dealt
with problems about housing, jobs, money, and legal rights.
Access to the group is open ended, with new members accepted through
professional or self-initiated referrals. In this way, older group members who
have made decisions to separate can function in advisory, almost co-leadership
roles. Newcomers may require orientation and special consideration if they are
to continue in the group long enough to benefit from it.
It is futile to encourage separation or to urge the woman to leave her partner.
Other people in the woman's life have probably attempted to do this in the
past, but to no avail. Initially, the woman needs help in restoring her
confidence and advice in meeting basic survival needs. Only then can she
decide whether to separate or to resume her marriage. Elbow (1977) listed
these alternatives for battered women: (1) she can leave, (2) she can continue
in the relationship hoping that her husband will change, or (3) she can
continue in the relationship while giving up hope that he will change. When
women opt for the second or third alternative; they are
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pregnant again shortly afterwards. Until the second pregnancy, her husband had
been neglectful but not abusive. He went out a great deal with
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male friends and lavished more attention on his motorcycle than on his family. The
second pregnancy embittered Shirley's husband, and the battering began almost as
soon as he learned that another child was expected. The violence quickly escalated
and nothing Shirley could do appeased him. She fled to the shelter after her
husband pushed her down a flight of stairs. Fearing for her son and her unborn child,
Shirley gathered a few belongings while her husband was out with his friends and
came to the shelter. When she called her parents to tell them where she was, they
told her that she should return to her husband "where she belonged."
Juliet worked as a waitress while her children attended school or a babysitter
watched them. Her relationship with her husband had always been stormy, even
before they were married. He drank excessively and resented Juliet's willingness to
laugh and joke with other men. Her explanation, that she flirted with male
customers in order to obtain larger tips, did not satisfy him. Many of the quarrels
between the couple were brawls rather than beatings. Juliet used any available
weapon to defend herself and attack her husband. Once she cut him with a broken
bottle, causing a laceration that required sutures. The recurring battles and
reconciliations did not upset Juliet greatly until her son, in trying to protect her,
received the blow intended for his mother and was knocked unconscious. The boy
was hospitalized for a week and expressed fears of returning home. A children's
protective agency investigated the entire incident and made Juliet realize for the
first time that she and her children could be seriously hurt. She came to the shelter
to think over her situation and deal with her son's fear of his father.
Both women were in the early stages of defining the problems in their marriages,
and neither was ready to divorce the abusive partner. Shirley's situation was more
difficult. With one small baby and another expected, she was unable to look for
work. Neither her husband nor her parents was willing to offer financial or emotional
support.
Critical Guidelines
The workers in the shelter watched with interest the growing friendship between
the two women. Juliet obtained a restraining order against her husband and through
a lawyer negotiated for child support and sole access to the apartment she had
shared with her husband. Although he begged for reconciliation, Juliet insisted that
her husband had to enter treatment for alcoholism and remain sober for at least a
year before she would discuss reunion. Shirley's husband had made no gestures
toward reconciliation, and despite pressure from her parents, she was afraid to
return to him. It was a great relief to her when Juliet asked Shirley to share her
apartment. In return for free housing, Shirley would care for Juliet's children when
they were not in school. This would relieve Juliet's mind and save the cost of afterschool care.
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When the shelter workers learned of the plan, they began to help with the logistics
of the move. Shirley applied for a support order and supplementary welfare. Some
nursery furniture was provided from donations made to the shelter. Together, the
two women met with a worker and were encouraged to work out specific aspects of
the living arrangement. Anticipatory guidance was used to avert potential problems
and clarify each woman's expectations of the other. They were encouraged to
commit themselves to the living arrangement only for a period of one year and to
review their situation at that point.
Sudden friendships are not uncommon among residents of shelters for battered
women. Some of these friendships are durable, but others are short lived. Because
of the temperaments of Shirley and Juliet, shelter workers believed this friendship
had a good chance of lasting. Juliet was the executive of this newly created
household, and Shirley respected this arrangement. Each woman was able to give
and receive something from the other. Because Shirley could help with child care,
she felt valuable and worthwhile. Her worries about her confinement were
minimized by Juliet, whose pseudosophistication concealed kindness and a strong
maternal drive. There was a chance that Juliet would return to her husband after a
year if he controlled his drinking problem. Shirley's marriage was less likely to be
resumed, but living with Juliet solved her most urgent problems and gave her time
to plan for the future. With independent Juliet as a role model, there was some
possibility that Shirley would eventually become more autonomous. Both women
were encouraged as ex-residents to participate in the support groups the shelter
staff offered.
Crisis intervention is necessary and appropriate in the first weeks after a battered
woman leaves her partner. Many women, however, are so demoralized by their
experience that long-term help is indicated. Curry et al. (1988) provided the
following guidelines for crisis counselors and for other health care providers working
with these woman:
Counseling a battered woman may be a lengthy process. These women respond to
a caring, empathic approach.
Although battered women feel inadequate and worthless, they need to begin to help
themselves. A counselor may help a woman discover alternatives, but the woman
herself should make the choices.
A battered woman feels that her whole life is out of control; she needs to learn that
she is capable of taking charge of her own life.
Help the woman sort out her confusion and conflicted feelings; assure her that her
terrible experiences can be used to avoid making the same mistakes in the future.
Encourage the woman to look at her situation realistically; support her during the
decision-making process.
Curry et al. (1988, p. 1190) wrote that battered women may "deny the past,
rationalize the present, and ignore the future." It
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may require persistent counseling for battered women to realize that they cannot
change the batterer very much. Only he has the power to change himself. The
woman, with adequate assistance and motivation, can find the courage to take
charge of her own future. Many battered women use community programs and
shelters to their advantage, but many others sentence themselves to a lifetime of
beatings, reconciliations, and shattered hopes. The following clinical example
illustrates an adverse outcome for one battered woman.
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became crueler and more perverse. His craving for cocaine escalated so that there
was no money left for food. When this happened, Ollie insisted that Meg prostitute
herself. At first she did well walking the streets, but with the arrival of winter,
customers were few. Ollie reacted by giving Meg a quota that she had to meet. Until
she fulfilled the quota, she was not allowed to come home. The night the police
found her, she had not met Ollie's quota and was afraid to go home.
Because of Meg's pattern of returning to Ollie, the staff at the shelter was not
hopeful that she would extricate herself from her miserable situation. Nevertheless,
they were committed to helping her and again placed the resources of the program
at her disposal. The telephone at the shelter was unlisted, and security personnel
prevented the entry of unwelcome spouses or boyfriends. Since no restrictions were
placed on outgoing calls or on the whereabouts of shelter residents during the day,
it was easy for any of them to contact old friends or to resume relationships with the
men they had just left. This was what Meg had done on her previous admissions,
and this is what she did during the most recent admission. As winter gave way to
spring, Meg evidently forgot about being forced to walk all night, freezing in a
skimpy outfit, and being unable to return home until she had made enough money.
On previous occasions she had told staff members when she was going back to
Ollie, always assuring them that things would be different this time. On the last
occasion of leaving, she left the shelter without a word of explanation. Other
residents told the staff that Meg had been seeing Ollie, that he was entering a drug
treatment program and needed Meg to help him. Meg had been too embarrassed to
inform the staff of her decision.
No one heard of Meg until the following winter when a news item appeared that she
had been found frozen in an unheated car where she had crawled for shelter, and
had fallen asleep. Her body showed signs of recent beatings by an unknown
assailant. When the police went to the address in her wallet, there were no signs of
the occupant with whom she had lived. Efforts were made to reach Meg's parents to
make decisions about a funeral. Her father told the city police to do whatever they
liked, because Meg ''had made her own bed and now she could lie in it."
Critical Guidelines
The news of Meg's death upset residents and staff members who had known her.
For battered women, this was a reminder of how precarious life with an abuser
could be. For staff members, Meg's death caused them to ask questions about their
effectiveness as counselors. Her records were reviewed in their entirety; in essence,
a psychological post-mortem was held.
Judging by the attitude of Meg's father, low self-esteem and lack of self-confidence
had been instilled in Meg as a child. Although she was young and pretty, she lacked
other social
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resources. She was poorly educated, even illiterate. Her knowledge of the world was
limited until she met Ollie. What he gave her was a dark world in which the strong
overpowered the weak, and in which a girl like her would never survive. Ollie was
able to convince Meg that she needed him because she could never take care of
herself. Prostitution was not something Meg engaged in willingly, because no love
was involved between the girl and the customer. What made it bearable for Meg
was awareness that she was a professional whore only because she loved Ollie so
much. With his sociopathic tendencies, Ollie was able to talk Meg into anything. She
wanted to believe in him and wanted to believe that eventually they would have a
fine life together as long as she did whatever he asked.
Counselors at the shelter knew that Meg lived in a fantasy world and hoped to make
her more realistic. Even so, they did not quite realize how frightened she was at the
prospect of being alone. Any contact with the welfare department or the housing
authority made Meg tremble with fear, although she concealed this under youthful
exuberance.
Almost all battered women have trouble accepting autonomy and independence, but
Meg's conflict was greater than most. In trying to learn something from Meg's death,
the staff concluded that they might have been more sensitive to her dependency
needs. One staff member, in particular, had considered Meg's distress less
overwhelming than that of resident mothers who had been abused. This counselor
told Meg more than once that she would very likely go back to Ollie, just as she had
in the past. Although it was too late for Meg, the counselor openly regretted her
remarks. She received some support from her colleagues, all of whom learned
something from their failure to help Meg.
Summary
The disorganized family is characterized by inappropriate role enactment and
recurring crises. For many of these families, alcoholism is not only a problem in
its own right, but is a condition that exacerbates the crises of spouse abuse
and child abuse. In modern life, domestic violence has reached epidemic
proportions, but has received public attention only within recent decades. Wife
battering is a practice that transcends ethnic and socioeconomic boundaries,
although it is more likely to be apprehended in lower-class families.
Psychoanalytic explanations of wife beating as a reciprocal sadomasochistic
interaction is not an adequate formulation, nor are sociological theories of the
etiology of spouse abuse.
The feminist viewpoint is useful for consciousness raising, but does not present
clear guidelines for clinical intervention. The reality is that family violence and
spouse abuse are complex problems that require an eclectic approach. Crisis
counseling has proved its effectiveness as a
Page 310
Fagan, J.A., D.K. Stewart, and K.V. Hansen. "Violent Men or Violent
Husbands? Background Factors and Situational Correlates." In The Dark Side
of Families Current Family Violence Research, edited by D. Finkelhor, R.J.
Gelles, G.T. Hotaling, and M.A. Straus. Beverly Hills, California: Sage
Publications, 1983.
Finkelhor, D., and K. Yilo. "Forced Sex in Marriage: Preliminary Research
Report." Crime and Delinquency 7(1982): 459-479.
___. License to Rape. New York: Holt, Rinehart and Winston, 1985.
Freud, S. "The Economic Problem of Masochism." In Collected Papers of
Sigmund Freud. New York: Basic Books, 1959.
Frieze, I.H. "Investigating Causes and Consequences of Marital Rape." Journal
of Women in Culture and Society 8(1983): 532-533.
Griffin, M. "In Forty-four States It's Legal to Rape Your Wife." British Journal of
Law and Society 9(1989): 21-23.
Page 311
Hanks, S., and P. Rosenbaum. "Battered Women: A Study of Women Who Live
with Violent, Alcohol Abusing Men." American Journal of Orthopsychiatry
47(1977): 291-306.
Helfer, R.E., and C.E. Kempe. Child Abuse and Neglect: The Family and the
Community. Cambridge, Massachusetts: Ballinger, 1976.
Hilberman, E. "Overview: The Wifebeater's Wife Reconsidered." American
Journal of Psychiatry 37(1980): 1036-1037.
Hornung, C., B. McCullough, B. Clove, and F. Sugimoto. "Status Relationships
in Marriage: Risk Factors in Spouse Abuse." Paper presented at annual meeting
of American Sociological Association, New York, August 1980.
Kurz, D. "Emergency Department Responses to Battered Women: Resistance
to Medicalization." Social Problems 34(1987): 69-81.
Lamb, S. "Acts as Agents: An Analysis of Linguistic Avoidance in Journal
Articles on Men Who Batter Women." American Journal of Orthopsychiatry
61(1991): 250-257.
Lesse, S. "The Status of Violence Against Women: Past, Present, and Future
Factors." American Journal of Psychotherapy 33(1979): 190-200.
Martin, D. "Society's Vindication of the Wifebeater." Bulletin of American
Academy of Psychiatry and the Law 5(1977): 391-410.
Meyers, L. "Battered Wives: Dead Husbands." In Family in Transition, 3rd ed.,
edited by A. Skolnick and J.H. Skilnick. Boston: Little, Brown, 1980.
Neidig, P.H., B.S. Collins, and D.H. Friedman. "Attitudinal Characteristics of
Males Who have Engaged in Spouse Abuse." Journal of Family Violence
1(1986): 222-233.
Pagelow, M.D. Women Batterings: Victims and Their Experiences. Beverly Hills,
California: Sage Publications, 1982.
Roy, M. Battered Women. New York: Van Nostrand Reinhold, 1977.
Saunders, D.G. "A Typology of Men Who Batter: Three Types Derived from
Cluster Analysis." American Journal of Orthopsychiatry 62(1992): 264-275.
Schechter, S. "Treatment and Advocacy of Battered Women: Principles and
Distinctions." Paper presented at Harvard Medical School Conference on Abuse
Page 313
PART FOUR
GROUPS IN CRISIS
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13
Communities in Crisis:
Disasters and Unemployment
If you have built castles in the air, your work need not be lost; that is where they
should be. Now put the foundations under them.
Henry David Thoreau
Page 316
sex, race, occupation, and marital status. The response of individuals to agent
factors depends on their levels of functioning, previous experiences, present
needs, and future goals. Agent factors include any stressors of sufficient
intensity and duration to produce disequilibrium in the host. An epidemiological
model of community crisis is depicted in Figure 13-1.
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Figure 13-1
Epidemiological Model of Communities in Crisis.
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depending on population density in the affected area and the support systems
available to stricken communities. Highly industrialized societies with dense
populations and complex technology are prone to greater impact, but have
more resources to alleviate suffering and disruption (Berren, 1980).
Human-derived disasters are more likely to be generated by events within the
community, whereas natural disasters originate outside the community and
may be less amenable to control. Strikes, riots, economic decline, and urban
decay are examples of human-derived, internally derived disasters. It must be
acknowledged that distinctions between natural and human-derived disasters
may be blurred in cases in which human ineptitude has aggravated natural
environmental hazards.
Another classification of disasters considers the expected or unexpected nature
of the disaster. Disasters that have occurred before or that give warning
signals allow for a degree of preparedness. People living in a valley that is
periodically flooded are more prepared to cope with flood control, just as
people living in the vicinity of a volcano have learned evacuation procedures
based on careful estimates of potential danger. Whenever the onset of disaster
is gradual rather than precipitous, those who are threatened have time for
anticipatory planning. Other factors that warrant consideration are the duration
of the disaster's impact and the broad distribution of consequences throughout
the population. When disasters are sudden, unprecedented, and
nondiscriminatory in their effects, there is greater likelihood of severe
community disruption.
Regardless of classification, disasters disturb community equilibrium and create
conditions of crisis. Natural and human-derived environmental disasters differ
in etiology, since the latter are a consequence of human decisions and actions.
Even so, the effects of natural and environmental disasters possess certain
similarities. This is not true of economic disasters, which have a uniqueness
that justifies separate classification. In this chapter, natural and environmental
disasters are discussed as similar phenomena, whereas economic disasters are
discussed separately because of their particular characteristics.
Natural and Environmental Disasters
Siporin (1976, p. 216) described disaster as "an extreme social crisis situation
in which individuals and social systems become dysfunctional and disorganized,
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TABLE 13-1 Location, Type, and Extent of Representative
Disasters, 1963-1991
Date
Location
Type
Extent
1963U.S.S. Thresher
Submarine lost
129 lives
1964Alaska
Earthquake
117 lives
Bay of Bengal, East
1970
Tidal Wave
200,000 lives
Pakistan
1974Zagreb, Yugoslavia
Train Wreck
153 lives
1974Darwin, Australia
Cyclone
67 lives
35,000
evacuated
1977Canary Islands
Airplane crash
582 lives
1979Chicago, Illinois
Airplane crash
272 lives
Ship and bridge
1980St. Petersburg, Florida
36 lives
collision
1981Las Vegas, Nevada
Hotel fires
92 lives
1983Victoria, South
Bush fires
72 lives
2000 homes
Australia
lost
1985Dallas-Fort Worth
Airplane crash
137 lives
Airport
30 injured
1985Armero, Colombia
Volcano erupted
22,000 lives
1991Philippines
Volcano erupted
341 lives
Source: Adapted from Janosik and Green (1992), Cohen (1987),
and Gavalya (1987).
Young children are apt to regress and cling to parents or favorite possessions
that have been rescued. Such regressive behaviors should be tolerated and
understood. Adolescents may display uncharacteristic behavior by becoming
withdrawn or belligerent. Either manifestation should be met with
consideration coupled with limit setting. Encouraging adolescents to assume
responsibilities that are constructive but not unduly demanding may help
restore age-appropriate behavior. For adults in the family, loss of home and
possessions is a bitter blow. Realization that the rewards of a lifetime of hard
work have been swept away may cause depressive reactions with
accompanying somatic complaints.
Many variables influence the readiness of victims to accept assistance. People
in lower socioeconomic groups are usually more willing to accept physical
treatment than psychological counseling. This is a compelling argument for
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The heroic phase appears at the time of the disaster and is characterized by
excitement and by people working together to survive the event. During the
heroic phase, panic behaviors are infrequent and maladaptive responses are
quite low. Fight-flight behavior is rarely evident and irrationality is notably
absent. Dynes and Quarantelli (1978, p. 235) wrote that ''solo or collective
panic is so rare as to be an insignificant practical problem." At this time, victims
adapt by assessing immediate exigencies and cooperating with others to
alleviate conditions. In the infrequent cases in which panic was evidenced,
there was urgent, severe danger arising within seconds, a limited number of
escape routes, and inadequate information, especially in regard to escape
routes. Three phases of disaster reactions appear in Table 13-2.
The period following the heroic phase has been labeled the honeymoon phase.
This interval is of fairly short duration, generally lasting from two weeks to two
months after the first impact of the disaster. During this time, optimism runs
high, and plans for rebuilding and restoring are formulated. In normal times, a
community attends to the production and distribution of goods, social control,
social protection, and social needs. During the honeymoon phase, community
priorities change; production of goods is reduced in importance because the
objective is to meet basic needs rather than maintain economic productivity.
Schools may be closed temporarily, and the media may become a means of
communication rather
Table 13-2 Theoretical Phases of Disaster Reactions
Time
Phase
Reactive Behaviors
Frame
Occurs
within two
Plans are made to rebuild and restore.
Initial, or
weeks to
Optimistic and energetic moods.
honeymoon two
Services regulated and allocated.
phase
months
Social control is high.
after
impact.
Appears Awareness of a new reality. Feelings
after a
of grief, anger, and despair. Feeling of
Middle, or
few
guilt for surviving. Irrational fears;
disillusionment
months; sleep disorders. Erosion of confidence
phase
may last a and trust. Rebuilding and restoring
year or so. begins.
May last Cooperative efforts to rebuild. Periods
Final, or
reconstruction several
of discouragement. Impatience with
phase
years or slow progress. Modification of values
more.
and expectations.
Source: Adapted
from Burgess
and Baldwin (1980).
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than a source of entertainment. Social activities assume a low profile, but social
control and social protection receive high priority. Mutual support among the
victims takes the form of regulating and distributing services in an equitable
manner unknown in the community before the disaster occurred.
Following these phases of work and optimism comes a period of
disillusionment, characterized by grief, despair, sleep disturbance, haunting
visual memories, and anger at the destruction of life and property. Burgess and
Baldwin (1980) suggested that this disillusionment phase might be compared
to a second disaster, whereby victims must cope with a new social reality
replete with losses, destruction, unemployment, and other problems.
Occasionally, the victims of disaster present depressive reactions, recurrent
fears, nightmares, and guilt for surviving when loved ones died. The
disillusionment phase may last from several months to a year or more. During
this phase, rebuilding is begun, but survivors may experience frustration and
failure. A sense of alienation, loss of confidence, and erosion of basic trust
compound these negative reactions.
The reconstruction phase can be identified by collaborative efforts designed to
restore predisaster levels of functioning to the community. Depending on the
magnitude of the disaster, this phase may last a number of years. During this
lengthy period, discouragement and apathy may surface if favorable results are
slow to appear. At other times, cooperation during the reconstruction period
causes people to draw closer to each other and perhaps modify their values.
According to Zeigler (1981, p. 9), in an interview with a flood victim seven
years after the disaster, the victim said, "A house is a very important part of
our lives-but it's not the most important part. Let me put it this way ... a home
could never be washed away ... but a house could." The following post-disaster
reactions are adapted from Cohen (1987):
Ambivalence about learning details of the disaster.
Unwillingness to accept the reality of losses.
Painful emotions expressed through somatic complaints.
Use of primitive defenses such as denial, withdrawal, and magical thinking.
Verbalizing painful emotions as the extent of losses are comprehended.
Burnout
During the period just after impact, disaster workers extend themselves
heroically. Professionals and paraprofessionals, and volunteers work side by
side to meet essential community needs. The unprecedented suffering that
surrounds the workers causes them to be unsparing in their attention to
survivors. An essential consideration for leaders of
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(1987, p. 1317) wrote, "In a disaster, the suddenness of death and the
catastrophic impact on individual lives produce both trauma and grief which
are sequential responses to the traumatic event." A disaster elicits conflicting
thoughts and feelings. Almost always, the survivors are flooded with anxiety
that impairs reality testing and alters the grief and mourning process. Cohen
and Ahearn (1980) stated that attention to survivors' anxiety should be the
first form of intervention.
According to Cohen (1987), survivors show a need to be active and an inability
to relax in the aftermath of a disaster. Their drive for action is often coupled
with indecision and social unresponsiveness. Although they wanted to be
active, survivors performed tasks in an automatic, blunted fashion. Crisis
workers need to be accepting of prolonged apathy; this reaction may be
related to trauma, but it also may indicate that grief work has begun. A related
issue is the importance of allowing survivors to express anger at helping efforts
without retaliation from care providers. It is quite usual for survivors to become
bitter and explosive as denial gives way to realization of what has been lost.
When survivors are irritable or uncooperative, it may precipitate similar
behavior in workers, some of whom risked a great deal in order to help. Mutual
withdrawal by care givers and survivors worsens the social isolation of
survivors.
The psychological distress of survivors is frequently expressed through
physiological channels. Many survivors have reported altered sensory
perceptions in the form of illusions, hallucinations, and delusions. Some have
described feelings of being out of touch with reality. This, at times, took the
form of refusing to believe that loved ones had died, and insisting that the
absent one would be found despite all evidence to the contrary.
Comparatively, little research has centered on children's reactions to disasters,
but some investigators (Galante & Foa, 1986; Terr, 1983) asserted that
children exposed to disaster are twice as likely to develop stress-related
problems later in life than children who were not similarly exposed. These
researchers found that traumatized children have fears that increase over time,
they cannot control their thoughts, they experience sleep disturbances, and
they have difficulty concentrating. Parents reported disobedience and
tearfulness; teachers reported inattentiveness and distractability. Parents and
teachers alike found that the children were restless and seeked attention.
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Interestingly, Murphy et al. (1990) reported that the veterans' experiences had
not made them less patriotic, and had increased their altruism.
The second theme the atomic veterans expressed was worry about the
intergenerational transmission of genetic defects. They worried about children
they already had and about their unborn grandchildren. The third theme was
protectiveness toward their children. Their wives also
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joined in this theme. Silence about radiation was invoked within the family so
the children would not be upset. In most instances, the children disclosed to
interviewers that they were well-aware of their parents' fears. The fourth
theme dealt with the legacy atomic veterans hoped to leave behind them. They
wanted public recognition of their experience so that future generations would
benefit. Some veterans found positive meaning in their illnesses and
disabilities, expressing a deeper appreciation of joys in the present. They clung
to hope that good might arise from their misfortune.
Counseling Victims of Unseen Disasters
Human-derived disasters are very hard for the families of victims because, in
many cases, the disaster was preventable. As atomic veterans have shown,
their reactions and those of their families are confused and labile. Often their
responses would alter drastically within a single interview. Their changeable
views ranged from wishing to be left alone, wishing to join with others, outrage
at their predicament, and altruistic concern for other people within and outside
the family. This complex range of responses has practical implications for
clinical intervention. Being exposed to toxic contamination of any sort evokes
images of futility and betrayal that repeatedly seek an outlet. In this context,
Heron (1981, p. 19) recommended that clinicians use "cooperative inquiry."
This would allow all participants to "contribute directly to hypothesis making, to
formulating the final conclusions, and to what goes on in-between." In light of
the atomic veterans' bitter criticism of the "certain" assurances the authorities
made amidst uncertain conditions, their participation in building hypotheses
and reaching conclusions seems essential. The same can be said of any
situation where a group or community must deal with unknown forces. The use
of cooperative inquiry can apply to any community looking for answers and
solutions to human-derived disasters. Edelstein (1988) described how
governmental agencies with jurisdiction over decisions are frustrating residents
of contaminated communities, especially when little is known of the ultimate
consequences. Atomic veterans, for example, claim that they were reassured
about safety limits for exposure, only to find that safety limits were revised
upwards when it was shown that the exposure levels of the veterans were
higher than safety levels previously set.
Economic Disasters
For people old enough to remember the Great Depression of the 1930s,
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tarnished. Men blamed themselves for their inability to provide for their
families, and housewives existed at less-than-subsistence levels in order to
offer more food to their children. Whenever there are more workers than jobs,
the concept of equal opportunity receives minimal attention. During the Great
Depression, people lucky enough to be employed allowed themselves to be
exploited in order to retain their precarious jobs.
According to a Johns Hopkins University study, a New York community
experiencing a 1 percent rise in unemployment may expect 5 percent more
suicides, 3 to 4 percent more hospitalizations for mental illness, 4 to 6 percent
more homicides, 6 to 7 percent more prison incarcerations, and a 2 percent
increase in the overall death rate (Bird, 1982). Some economic disasters are
national in scope and have a rippling effect that carries economic
consequences beyond national borders. The Great Depression was a worldwide
phenomenon and probably contributed to upheaval that led to the outbreak of
World War II. Lesser economic disasters are more circumscribed, and their
impact is felt only in one region or by one segment of workers. A singleindustry town may become a disaster area as a result of a corporate decision to
relocate a factory. Technological changes or reduced demand for certain
products may cause large-scale layoffs of workers, some of whom must retrain
or relocate in order to become employable.
Being laid off, even temporarily, is an awesome experience for contemporary
workers, for it is a dramatic reminder that the individual is expendable. Even
the fortunate workers who retain their jobs when others are laid off fear that
their luck will not last forever. Economic disaster in the form of massive
unemployment makes everyone anxious-families, friends, and business people
who must depend on the purchasing power of working men and women.
Whenever there is widespread economic adversity, mental health facilities
report an increase in the number of people seeking help. Massive
unemployment can precipitate community disruption in the form of vandalism,
riots, and looting. Family conflict is a by-product of troublesome economic
conditions. Not only is marital maladjustment more prevalent, but parents and
children seem to have more difficulty with each other. In Hartford,
Connecticut, one out of eight workers laid off by an aircraft factory reported
that their marriage deteriorated as a result, and 15 percent reported more
quarrels with their children (Pines, 1982). The same source observed that
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reaches a level at which people can no longer function as social beings. When,
for example, parents must keep their children home from school because there
is no money for athletic equipment or school outings, neither the parents nor
the children are able to perform their socially accustomed roles. Communities
have definite expectations of family in various socioeconomic strata, and the
families have certain expectations of themselves. These expectations cannot be
fulfilled in periods of severe economic decline, and the result is family
disequilibrium expressed in
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discord between spouses, between parents and children, and between families
and community institutions, such as school, business, and the legal system.
Several investigators have found a relationship between unemployment and
health. In Canada, the United States, and other developed countries,
researchers have found increased mortality rates for unemployed people, even
when rates consider socioeconomic factors. Health risks of unemployed workers
extend to all family members, from infants to adults to the elderly. Although
Zuravin (1988) found no association between child abuse and parental
unemployment, other studies suggested the contrary (Zlotnick & Cassanego,
1992).
Unemployment insurance is based on previous earnings. This means that
families unlikely to have a financial cushion receive less in the way of benefits.
Without steady employment, the worker finds himself and his family without
health or medical coverage. Nutritional standards are abandoned, as adequate
diets become unaffordable. As Zlotnick and Cassanego (1992) bluntly stated,
The literature is very clear: Unemployment is associated with increased stress and
morbidity for the worker and spouse, and this stress may eventually have an impact
on the workers' children. The clear indication for the public health sector is that
unemployed workers and their entire families need ... intervention, particularly
preventive health care (p. 80).
just lost a job. Remember that being laid off is an affront and a body blow to a
conscientious worker. The best way to handle the situation, whether the
jobless person is a friend or an
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ner. This role shift is difficult for couples, even in families in which there is little
emphasis on gender-differentiated role enactment.
When the parents are feeling uncomfortable with the role changes in the
family, the children are invariably affected. A child who was fairly well adjusted
at home and at school may begin to fail academically, withdraw, or become
obstreperous. Well-meaning parents may try to shield children from the facts
by glossing over or not explaining the problem. This avoidance makes it difficult
for children to understand the reason for family tension. The result is that they
may engage in fantasies of separation or family dissolution that are more
frightening than the reality from which they are being protected. Even when
this fantasizing does not happen, the children feel excluded rather than part of
a family system in which every member must adapt to new conditions.
Role enactment tends to be stabilized in functional families, with varying
degrees of role flexibility. Economic disaster can dramatically change role
enactment and role distribution in families when the primary provider becomes
unemployed. This shift is particularly difficult in traditional families in which role
changes are not easily accepted. If individuals in the family are externally,
rather than internally, directed and ascribed roles are highly valued, the loss of
conventional role enactment may lead to feelings of depersonalization or
nihilism. Other individuals prove able to adapt to new role dimensions in
productive ways that eventually enhance self-esteem and family perception of
itself as a working, functional system.
Loss of morale and deprived feelings characterize families faced with indefinite
periods of employment. Crisis counseling cannot produce jobs, but can help
make the period of unemployment less bleak. Group counseling programs for
unemployed workers, for their spouses, and children are perhaps the best form
of supportive work. These programs can range from vocational retraining for
workers whose skills are obsolete to emotional support for workers who blame
themselves for being unemployed. Shared unemployment in a community
tends to reduce the guilt and self-blame of the workers but perhaps intensifies
their feelings of powerlessness. Unemployed men usually feel a loss of role and
status within the family, particularly if authority was dependent upon the man's
economic contribution. Abandoning the meaningful family role of provider adds
to the frustration of the unemployed worker, even when family affection is
strong and role flexibility can be accomplished within the system.
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and this externalization is less destructive than the self-blame of workers or the
scapegoating of a family member. However, anger should not be allowed to
continue to the extent of immobilizing the problem-solving potential of the
family. General precepts of crisis intervention that permit catharsis before
moving on to productive problem solving can reduce confusion and depression.
Assessment of family resources in terms of marketable skills and willingness to
relocate can help the members focus on strengths rather than weaknesses.
Jobless people see themselves as victims of economic disasters. They deserve
to be helped in ways that avoid any hint of blame or stigma. There is genuine
need for retraining, social action programs, and self-help groups operating on
behalf of the unemployed. Referrals for mental health counseling are
imperative when there is emotional distress in the wage earner and turmoil in
the family.
Clinical Example: Family Construction of a Libidinal Cocoon
At 5:04 P.M. (Pacific daylight saving time), an earthquake measuring 7.1 on the
Richter scale struck the area of northern California surrounding San Francisco. The
epicenter was about sixty miles south of the city in the Santa Cruz Mountains. There
were damage, deaths, and injuries from Santa Cruz to the San Francisco marina,
and the city of Oakland. The economic costs of the disaster were estimated at more
than $8 billion. Sixty-two people died and 3,000 were injured. About 116,882
buildings were damaged; 14,000 people were made homeless (Laube-Morgan,
1992).
When they felt the first tremors, Vincent and Maria Garcia were at home preparing
dinner. The couple were in their middle fifties and the parents of five children, all of
whom were married and lived in their own homes. The Garcias owned and operated
a shoe repair shop in a business section of San Francisco, a short distance from the
house they owned. As a young, married couple, Vincent and Maria had come to
California from Mexico. They joined relatives in the states, were sponsored
legitimately, and adjusted well to American life. Their children were natural born
Americans. Vincent and Maria were proud of that fact and of the hard won
prosperity they now enjoyed.
When the house began to shake and dishes flew off the shelves, Vincent knew at
once what was happening. He grabbed his wife by the waist and pulled her under
the kitchen table. Huddled together, arms round one another, they listened to the
sounds of glass breaking and doors banging open and shut. A heavy bureau fell over
in a bedroom and Maria screamed that the ceiling was caving in. She moaned and
said prayers for the safety of her children and grandchildren who were somewhere
in the city. Between prayers, she wept at the destruction of her cherished
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told her fiercely that this was no time to cry about dishes. He added that Maria
already had too many dishes and they could get along on whatever was left. When
the kitchen clock fell off the wall and crashed onto the floor Maria screamed again;
Vincent told her to get hold of herself. He said he would get her a new clock, but
only if she stopped crying and praying. All this made Maria cry and pray more than
ever, but it had the expected effect of making her angry with Vincent rather than
afraid.
It seemed like a lifetime before the tremors stopped. After a time, the Garcias crept
out from under the table to examine the damage to their home. Within an hour their
daughter Rita arrived to make sure her parents were safe. Her husband was a police
officer who came with her, bringing along their six-year-old son. The son-in-law
stayed only a few minutes because he had to report on duty. Rita, who was a nurse,
wanted to go to the nearest hospital to help but decided she would stay with her
parents until hearing from the rest of the family.
Maria was worried about her four sons and their families, and Rita tried to reassure
her. Because the earthquake occurred near the end of the day, most of the children
were home from school. Substantial numbers of workers whose day ended at 5:00
or 6:00 P.M. were still trapped in the city, inside buildings or on the streets. The Bay
Bridge had collapsed with the first tremors, hurtling cars and people into the bay.
Public transportation was at a standstill and most phone lines were down. To help
commuters get home, sight-seeing ferries were pressed into service. Most of these
people were able to get to their homes by midnight. Until then, worried families
waited without news.
Vincent found it intolerable to wait at home. Maria and Rita protested, but he
insisted on leaving the house to go to his store. Instructions were being broadcast
that empty houses, offices, schools, and other buildings the earthquake had
damaged were off limits until inspectors certified them as being safe. Maria thought
they all should leave the house, but Vincent told them to stay where they were.
Restless and anxious, he found inactivity unbearable. He was, in fact, more worried
about looters than about collapsed buildings. After he arrived at the store, he found
neighbors assessing the damage to their business places, talking about what they
were doing when the earthquake struck, and wondering what to do next. Vincent
was not a patient man, and he quickly tired of his neighbors' idle talk. He was more
impressed with the work of police officers, firefighters, and a few volunteers
searching for people who might be trapped under debris. Explaining to one police
officer that he had a son on the force, he offered his assistance. For the next four
hours he was kept busy cleaning up streets and erecting barricades around perilous
buildings. Tired and hungry, he finally decided it was time to go home, but promised
to be back the next day.
On arriving home, he found that his wife was very worried about him. Rita's husband
had stopped by to say that he had located all four brothers and their families. Two
of them had been evacuated from their homes and were in a school being
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used as a shelter, but planned to come to their parents' home the next day. With
her daughter's help, Maria had managed to prepare an evening meal. Vincent's
share was warmed up. He ate his supper and persuaded the other family members
to get some sleep. Maria again warned that the house was probably unsafe, but she
had no idea where else they should go. The block where the store was located had
been cordoned off but the blocks around the house were still accessible. This helped
convince Maria that they could go to sleep.
A second earthquake struck at 7:30 A.M. This time the four members of the Garcia
family left their house for several hours and were allowed back because their area
suffered minimal damage. Elsewhere they saw buckled sidewalks, uprooted trees,
overturned cars, and demolished or barely standing buildings. During the day, the
rest of the family joined the group, bringing food and blankets. They had decided to
accept Maria's invitation and Vincent's command that they all stay together until the
city was back to normal. With her sisters-in-law available to care for her son, and
with cousins as playmates, Rita decided to go to the nearest hospital where she
knew she was needed. One sister-in-law, who had spent the previous night in a
shelter, decided to return to the shelter to help with the cooking. Vincent and his
sons felt that able-bodied men were absolutely essential for cleaning up the area
around the marina and left to see what they could do. With her daughters-in-law
and grandchildren around her, Maria was able to push her worries aside. It was
always a treat for her to have everyone near. During the next few days, mealtime at
the Garcia's household became almost festive. In the secure domestic atmosphere,
lost cars and damaged homes did not seem so overwhelming. Members who were
working with less fortunate survivors, recounted some tragic stories. This made
them much more resigned to their losses, and grateful for being alive and together.
Critical Guidelines
The combined property damage the extended Garcia family suffered was
considerable. In an ordinary situation, this would have been very distressing, but
after the earthquake they saw property loss as inconsequential. Except for the
children, some of whom suffered night terrors about the earthquake, the other
family members showed no negative effects. Vincent Garcia reacted in his
customary style. He took charge of his wife and his household, and used purposeful
activity to deal with his anxiety. Once he learned that all the family members were
safe, he minimized the importance of property damage. He was gratified that his
home had been used as a haven for the whole family. Moreover, he was proud that
he, his daughter, all his sons, and a daughter-in-law had extended themselves to
help others during the emergency.
Maria was a religious woman who believed that her prayers were answered when
family members were unhurt. Her life was
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more home centered than that of her husband; in caring for her family, she was able
to suppress her knowledge of possible danger. Even though her husband often
infuriated her, his firm way of dealing with events made her feel safe. To avoid
adding to her emotional distress, Maria stayed at home when the rest of the family
went outside to help or simply to view the damage. Most of the time, everyone
stayed quietly together.
In forming a tightly knit family group, the Garcias unknowingly replicated the
"libidinal cocoon" that Black (1987) described. In 1985, the families of 137
passengers killed in a Delta plane crash were placed in a secluded hotel while
waiting for bodies to be recovered and identified. In this protected environment,
known as a libidinal cocoon, a mental health team composed of a psychiatrist,
nurses, clergy, and hotel and airline agents cared for and nurtured the families. The
bereaved families gradually interacted on an intimate basis and responded to each
other's pain. Inside a warm environment, families were allowed to regress as they
wished, secure in the knowledge that every physical or emotional symptom they
experienced would be ministered to. Survivors of the plane crash were placed in the
same secluded environment and received the same tender care. As Black (1987, p.
1324) described, "Soon they were able to laugh and cry at the same time and to
accept nurturing from a variety of helpers. Before long they could reach out to
others." Family members and survivors who chose not to stay in the protective,
cocoon-like environment that was made available exhibited more signs of
psychiatric disturbance than did those who allowed themselves to be cared for.
In many ways, the Garcia family formed its own libidinal cocoon. Their behavior
followed most of the recommendations made in operationalizing this form of
treatment. The recommendations are as follows:
The presence of a strong caretaker or caretakers is needed.
Interactions with the outside world are limited or controlled.
The people who have experienced disaster or loss are encouraged to regress.
Physical, emotional, and behavioral needs are met to the fullest possible extent.
Denial is permitted as long as it is adaptive and necessary to maintain individual
and family equilibrium.
The entire process of offering nurture, care, solicitude, seclusion, and understanding
continues without interruption and as long as necessary (for example, for hours or
days).
Since this airline crash, the libidinal cocoon has been used several times, with good
results. The United States Army used this approach after an air crash in
Newfoundland that killed two hundred servicepersons; officials also used it in Texas
after the Guadalupe River flooded, killing ten children who attended a religious
school. Here, regression and the religious implications
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of untimely death were used to comfort families. In both instances, families were
secluded and protected from the demands of the outside world.
Summary
Community crises may result from disasters that affect segments of the
population rather than single families or groups. Disasters are diversified in
nature, and several typologies can be used to differentiate forms of disaster,
even though distinctions are sometimes blurred. Disasters may be expected or
unexpected, recurrent or unprecedented. They may be natural occurrences or
the result of human-derived decisions about the environment. Some disasters
are generated by forces external to the community; others are the result of
internal forces.
By using an epidemiological model, most responses to disaster can be
discussed in community terms. Despite popular beliefs, imminent disaster does
not usually cause panic, although the actual impact may precipitate varying
degrees of disorganization. Victims can depend upon the durability of roles
among police officers and firefighters, although the work of all rescuers is
enhanced if they remain in communication with their own families. The
possibility of burnout among rescue workers must not be discounted, and
leaders of rescue operations should assume responsibility for identifying
burnout. Some experts have formulated three stages of response to disaster,
but others see greater variation in survivors' reactions. Most survivors require
only crisis intervention, which is most effective if integrated into comprehensive
relief programs. There are some vulnerable individuals who suffer long-term
effects that require sustained intervention.
Economic disasters possess a uniqueness that warranted their discussion as
separate phenomena. As in all disasters, massive economic adversity affects
role enactment. Families in which role flexibility can be maintained are more
likely to adapt successfully to conditions of severe economic deprivation. A
recommended form of primary prevention would require employers to give
advance warning of layoffs or shutdowns so that workers can adjust, relocate,
or retrain during periods of economic decline. The importance of supportive
family counseling and problem-solving approaches to the alleviation of
economic disaster cannot be overemphasized.
A relatively recent approach to helping people cope after disaster is the
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some instances. The clinical example described a family who survived a severe
earthquake in California. Without any previous knowledge, this family virtually
created for its members a libidinal cocoon that reduced the earthquake's
psychological impact. The libidinal cocoon offers a contrast to reality-based
crisis intervention, but it has powerful implications for crisis workers in shelters
and dining halls where people come for help after a disaster has displaced
them from their homes.
References
Berren, M.R. "A Typology for the Classification of Disasters." Community Mental
Health Journal 16(1980): 103-110.
Bird, C. "Joblessness Scars Deeper than Simple Totals Tell." The Plain Dealer
April 10, 1982.
Black, J.W. "The Libidinal Cocoon: A Nurturing Retreat for Families of Plane
Crash Victims." Hospital and Community Psychiatry 38(1987); 1322-1336.
Bovard, E.W. "The Effects of Social Stimuli in Response to Stress."
Psychological Review 66(1959): 267-277.
Briar, K.H. "Unemployment: Toward a Social Work Agenda." Social Work
28(1983): 211-223.
Burgess, A.W., and B. Baldwin. Crisis Intervention Theory and Practice: A
Clinical Handbook. Englewood Cliffs, New Jersey: Prentice-Hall, 1980.
Camus, A. The Plague, Translated by Gilbert Stuart. New York: Random House,
1948.
Cohen, R.E. "The Armero Tragedy: Lessons for Mental Health Professionals."
Hospital and Community Psychiatry 38(1987): 1316-1321.
Cohen, R.E., and F.L. Ahearn. Handbook for the Mental Health Care of Disaster
Victims. Baltimore: Johns Hopkins University Press, 1980.
Donovan, R., N. Jaffe, and V.M. Pirie. "Unemployment Among Low Income
Women." Social Work 32(1987): 301-305.
Dynes, R., and E.L. Quarantelli. "The Family and Community Context of
Individual Reactions to Disaster." In Emergency and Disaster Management: A
Mental Health Source Book, edited by H.J. Parad, H.L.P. Resnik, and L. Parad.
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14
Society in Crisis:
AIDS and HIV
The mutual confidence on which all else depends can be maintained only by an open
mind and a brave reliance upon free discussion.
Learned Hand
AIDS (acquired immune deficiency syndrome) and its rapid proliferation within
a short period of time have created a pattern of crisis for many individuals,
families, communities, and nations. In this chapter, the AIDS parameters are
discussed, beginning with the crisis that ensues when individuals first discover
that they are HIV (human immunodeficiency virus) positive, indicating that
they harbor the virus that causes AIDS. As HIV infection progresses, the
depressed immune system of seropositive individuals renders them susceptible
to recurring infections that resist treatment. While some of these infections can
be overcome, others continue to develop. For HIV-positive individuals, every
serious illness may precipitate another crisis. Because the course of HIV
infection and AIDS is unpredictable, and the general prognosis is poor, ways
must be found to prevent further contagion, to help infected persons maintain
a satisfying life as long as possible, and to care adequately for them during the
advanced stages of their illnesses.
Not only individual, but also the families of HIV-positive individuals and AIDS
patients face critical challenges. Discussion of AIDS-related family crises is
included in this chapter. Demands made on health professionals caring for
AIDS patients are very heavy and are compounded by fears of contagion. Like
infected individuals and their families, people taking care of AIDS patients
benefit from supportive counseling that enables them to avoid crisis by meeting
their own physical and emotional needs. Therefore, this chapter offers a
realistic view of HIV and AIDS in the context of crisis prevention and
intervention.
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In the 1960s and 1970s, people were vaguely aware that disrupting the
balance of nature could have far reaching implications on world health. They
were unprepared, however, for the rapid transmission of HIV and AIDS
throughout the globe. The reason for this global transmission is neither obvious
nor simple. Perhaps Richard H. Krouse, former director of the National Institute
of Allergy and Infectious Diseases that is part of the National Institutes of
Health (Henig, 1992), gave the most convincing explanation.
A major dislocation in the social structure-love, hate, peace, war, urbanization,
overpopulation, economic depression, people having so much leisure that they sleep
with five different people a night-whatever it is that puts stress on the ecological
system, can alter the equilibrium between man and microbes. Such great
dislocations can lead to plagues and epidemics, more often than not caused by
microbes that already reside on our doorstep (p. 55).
look and feel well. The long latency period gives the carriers ample opportunity
to infect others before they themselves become ill. Given the extended latency
period of the virus and the
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propensity of many individuals for sexual risk taking, it is not surprising that an
estimated ten million people around the world are HIV positive. Within the
United States, more than one million Americans (1 out of 250) are estimated to
be HIV positive. The majority of HIV-positive Americans are between twentyfive and forty-four years of age, usually a time of greatest productivity (Noble,
1992). In 1993, more than 365,000 Americans will have been diagnosed with
AIDS, with the annual death toll in excess of 170,000 (Leukefeld, 1989).
Within the last ten years, AIDS has assumed the proportions of a medieval
plague. Initially, its prevalence within the homosexual community and in
underdeveloped countries allowed many people to feel uninvolved. Moralists
attributed the spread of AIDS to perverted or promiscuous sexual practices,
going so far as to call AIDS a form of divine retribution. Very soon, though, the
AIDS virus proved not to discriminate against race, age, nationality, gender, or
sexual preference. This is no longer a minor epidemic confined to a particular
community, eventually abating. Already the disease has decimated
communities of people in the creative arts, in inner-city neighborhoods, and in
developing countries. The virus has crossed national boundaries, contaminated
blood supplies, intruded into heterosexual and homosexual encounters, and
doomed hapless children-all within the space of a few years.
AIDS Parameters
AIDS is an infectious disease characterized by a latency period, acute episodes,
chronicity, and ultimately death. AIDS was first identified in the United States
in 1981 when two men died from a type of pneumonia that was seldom fatal.
These men succumbed because their immune systems were depressed. It is
now known that AIDS is an infection caused by a retrovirus, i.e., human T-cell
lymphotropic virus type III (Human TLV-III Lav). There are three stages of the
infection. At first an individual may be seropositive but have no symptoms. In
the second stage, known as AIDS-related complex (ARC), the individual may
experience swollen glands, fever, night sweats, and weight loss. The third
stage is characterized by severe immunodeficiency and such complications as
Kaposi's sarcoma or pneumocystis carinii pneumonia (Perry & Markowitz,
1988).
No illness arouses more dread than AIDS nor carries more stigma. Although
AIDS is no longer confined to any one group, there is a tendency to categorize
the sufferers. There are the "innocent" victims who were infected by a legal
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Ours is a society that looks for connections between cause and effect. We have
solved so many mysteries already that we continue to search for answers no
matter how elusive. Our wish to understand and alter events makes us
impatient with illnesses that do not respond to available resources. Thus, when
a chronic or incurable illness develops, we tend to blame the victim.
It is true that many behaviors do contribute to ailments and disabilities.
Smoking, alcohol abuse, and indiscriminate sexual habits certainly constitute
risk factors. However, the time to call attention to reckless, self-defeating
behavior is when the behavior is exhibited, not after serious illness has
appeared. Once an illness has developed, it is cruel to remind the victim of her
own contribution. The sick person will not benefit from self-recrimination and
will be less able to cope if energy is wasted in guilt. Matter-of-fact
acknowledgment of contributing factors is permissible, but should be laid aside
so as to deal with more pressing matters (Wechsler, 1990).
Flaskerud and Thompson (1991) called attention to a valuable message that
behaviors spread AIDS, not any single group. This message is essential, since it
is white, heterosexual persons who are more likely to deny their vulnerability,
and more than any other population segment have not changed their sexual
behaviors.
Activist groups have accused the U.S. government of mounting an inadequate
campaign to combat the AIDS epidemic. Without taking sides in the debate, it
is possible to state that further efforts are needed to finance research;
establish additional programs; formulate practical, effective legislation; educate
the public; and encourage community involvement. As Figure 14-1 indicates,
worldwide, the number of reported AIDS cases is dramatically lower than the
estimates. This is due to underreporting, delays in reporting, and
underdiagnosis.
At present, the most effective way of preventing the spread of AIDS is to use
preventive measures. Family members and health care professionals should
understand the following recommendations of the U.S. Public Health Service
regarding AIDS transmission, and impress these upon clients at risk (U.S.
Public Health Reports, 1988).
Avoid sexual relations with persons having AIDS or persons belonging to any
group at risk for contracting AIDS.
Avoid sexual relations with multiple partners or with anyone who has multiple
partners.
Do not give blood if you have AIDS or are at risk of contracting AIDS, i.e., HIV
positive.
Exercise extreme care in handling, using, or disposing of hypodermic needles
and syringes in all health facilities.
Do not use intravenous drugs. If you persist in this unsafe practice, do not
share intravenous equipment with others.
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Figure 14-1
Estimated AIDS and HIV Cases vs. Reported AIDS Cases
(Cumulative Number Reported to the World Health Organization as of March 1992).
Any woman using intravenous drugs or having sexual relations with a high-risk
partner should practice contraception. If she becomes pregnant, she is likely to
transmit AIDS to the unborn child.
HIV-positive Individuals
Many researchers oppose compulsory or mass HIV testing because of imprecise
results. It may take six to twelve weeks for an HIV-infected person to develop
enough antibodies for a positive result. Within this interval, results are liable to
be falsely negative. Mass screening for HIV often produces false positive
results, as do home testing kits. A seronegative person who has engaged in
high-risk behavior should be retested at two-month intervals. Perry and
Markowitz (1988) reported that, in the United States, roughly 35 percent of
seropositive persons will develop AIDS within the next seven and a half years;
40 to 45 percent will develop ARC with its accompanying symptoms. About 20
percent of HIV-positive persons will remain symptom-free. Advisors and
counselors should realize that these statistics are frequently revised and
therefore should review Morbidity and Mortality Weekly Reports, which the
Centers for Disease Control publish.
For many individuals, AIDS becomes a threat only when they learn that they
are HIV positive. For many, this represents a crisis that is met with denial and
refusal to accept the full implications of positive testing.
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Since these individuals may be symptom-free for some time, denial may be
relatively easy to maintain. This is a dangerous state of affairs unless the
individuals are willing to act responsibly toward sex partners.
It is true that the AIDS epidemic has led to changes among some segments of
society. The gay community is mobilized and unified as never before. Even
among homosexual people, the behavioral responses of people who are HIV
positive are not very encouraging. Perry and Markowitz (1988) reported that,
after testing HIV positive, homosexual men do reduce the frequency of highrisk sexual encounters, but over 30 percent of seropositive homosexual men
continue to engage in unprotected insertive anal intercourse with multiple
partners. Gay men who were found to be seropositive had an average of 5.8
sexual partners in a year and only 46 percent in the sample consistently used
condoms after being told of their status. Based on fifty studies conducted in
twenty-three cities, the Centers for Disease Control (1987) estimated that,
overall, about 20 to 25 percent of homosexual men are HIV positive, but in
some localities, about 68 percent may be seropositive.
The Centers for Disease Control estimates that, in New York City and in Puerto
Rico, 50 to 65 percent of intravenous drug users are seropositive; elsewhere in
the United States, less than 5 percent of intravenous drug users are HIV
positive. For persons with hemophilia, the Centers for Disease Control
estimates of HIV prevalence range from 65 to 70 percent. These rates are
moderately lower than earlier statistics. For bisexual men, seropositive rates are
about 5 percent, provided their homosexual encounters are infrequent.
Heterosexual partners of persons who are HIV positive or are in high-risk
groups show great variation in seropositive rates; the range of HIV positive
readings among this group is between 10 and 60 percent. In the general
population without identified risks, seropositive rates are about 0.02 percent
(Curran et al., 1988; Booth, 1988).
Counseling the HIV-positive Individual
When an individual is HIV positive, every unprotected sexual transaction,
especially if the partner is HIV negative, is a violation of the partner's rights.
Upon discovering that they are seropositive, some individuals are so angry that
they want others to share their misfortune and knowingly choose to put others
at risk. Others want to warn their previous partners and urge them to obtain
testing and treatment, if necessary. Regardless of their reactions, most HIV-
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personal physicians, dentists, and nurses of the test results. At the same time,
they may be permitted to be selective in telling employers, landlords, and
casual acquaintances, who are not being placed at risk. The counselor should
ask where the seropositive individual plans to obtain further treatment and
advice. It is appropriate to make referrals or even set up appointments for
follow-up care when the individual is too distressed to do this. Even when
essential information has been covered
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fully, continuity of care is essential for the individual and for other people.
When condoms, for example, are advocated to prevent viral transmission,
explicit instructions are needed. The sexual encounter can be considered safe
only when the individual uses latex (not sheepskin) condoms, applies a
virucidal contraceptive jelly, and follows detailed instructions for wearing and
discarding the sheath. Directions may be given during post-test counseling,
but ongoing clarification is almost always needed (Hicks et al., 1985).
The Individual and AIDS
The onset of weight loss, intransigent infections, atypical pneumonia, the
lesions of Kaposi's sarcoma points to the presence of an AIDS-related illness
and introduces a new period of crisis. The individual's watchfulness and careful
living are no longer sufficient, and the individual must face a new situation.
Friends and family usually must be told, if they do not already know. Some will
rally to help the person who is ill, but others will turn away.
In addition to being ravaged by illness, AIDS patients face a frightening future.
Moreover, if they are homosexual or are drug addicted, social and emotional
problems with lovers, spouses, or parents may add to the stress of the
situation. Persons suffering from AIDS need a wide range of services, not all of
which are available across the country (Chaches, 1987).
Housing. Misconceptions about contagion and transmission modes make it
difficult for persons with AIDS to obtain and keep adequate housing.
Finances. Costs of treatment for AIDS are staggering. Even when
hospitalization is avoided, medications are extremely expensive. Jobs are lost;
insurance is canceled or benefits are exhausted. Impoverishment is added to
the indignities of the disease.
Home care. Persons with advanced AIDS are likely to be hospitalized three or
more times within the span of a year. Between hospitalizations, home care
services are essential, especially if no hospice or voluntary caretaker is
available.
Childcare and foster care. Mothers with AIDS and mothers of children with
AIDS need childcare in order to keep appointments for treatment. Temporary
foster care may be needed when the mother is hospitalized; permanent foster
care may be needed when the mother dies.
Legal counsel. Decisions about child custody, power of attorney, wills, and
bequests require legal assistance.
Medical care. Different kinds of treatment are indicated at different stages of
illness. In addition to medical treatment, nursing care and mental health
counseling may be needed. A health care professional should act
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as case manager and coordinate various aspects of care. The coordinator, who
may be a member of any major health care discipline, should assume
responsibility for teaching, explaining, and humanizing procedures as much as
possible.
Public education. The person suffering from AIDS, along with concerned
friends and relatives, deserve accurate, up to date information about AIDS,
with emphasis on prevention measures.
Denial is often considered an indication that an individual is not responding
realistically to a life situation, but denial can be an intricate mechanism. Some
individuals who are seropositive deny some aspects of AIDS but accept other
aspects. Frequently, denial is expressed verbally but not behaviorally. Saunders
and Buckingham (1988) cited an example of one infected person who claimed
that he could not have AIDS because he felt so well. At the same time, his
actions showed considerable awareness of his circumstances. This person was
a male homosexual who asked his lover to move out of the house they shared
so that the lover would not become infected. He also arranged with his
employer to work at home in order to protect his associates at the office. Thus,
even though he did not acknowledge all aspects of his infection, his denial was
not complete.
Partial denial may be functional if it motivates the individual to feel optimistic
and autonomous. Instead of opposing denial, it is better to build on what the
individual is able to accept. Despite his insistence that he would not fall ill, this
individual realized the hazards that were present and tried to protect others.
His decision to live apart from his lover can be supported without suggesting
that the relationship should be terminated altogether. There are many ways of
encouraging AIDS patients to stay in control. One way to accomplish this is to
provide accurate data on which to base their decisions and to encourage them
to explore options and alternatives. The following, adapted from Saunders and
Buckingham (1988), lists guidelines for counseling AIDS patients:
Include biopsychosocial assessment in every interaction.
Observe and listen without overreacting. Overreacting may elicit negative
responses, such as fear or resistance.
Understand and follow local legal standards, agency policy, and ethical
obligations.
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Do not ignore the strong emotions that working with an AIDS-infected person
can arouse. If you are to be therapeutic, you must stay in touch with these
emotions. Suppressing them will reduce your effectiveness.
Management Styles of AIDS Patients
Ragsdale et al. (1992) explored the quality of life from the viewpoint of AIDS
patients. The investigators identified six management styles these patients
used to solve aspects of their illnesses. Because the authors suggest that
quality of life for AIDS patients can be improved if others recognize and accept
their chosen management style, descriptions of the various styles is appropriate
here. Care providers soon learned there were significant differences in the
ways patients responded to their illnesses. As care providers became aware of
distinctive styles, they shaped their interventions accordingly. The six types of
management styles were as follows: loner, activist, mystic, victim, timekeeper,
and medic. Neither the staff nor the caregivers applied these terms
pejoratively, but they used the terms descriptively to develop helpful
interactions between staff and patient.
The Loner
The loner is a patient who tends to avoid social interaction whenever possible.
The loner spends as much time as she can either sleeping or reading. Although
the loner resists attempts others make to talk about AIDS or its implications,
she does not avoid all social interaction. She likes some care providers more
than others and recognizes efforts staff members make on her behalf. She
discourages support groups and communication with other AIDS sufferers.
Neither friendly nor hostile, the loner simply does not want intimate
communication with anyone.
The Activist
Unlike the loner, the activist does not avoid interaction with others. This
individual manages his situation by immersing himself in the larger issue of
AIDS. His personal dilemma is seen as a collective problem, and he derives
satisfaction by trying to help others within the structure of a support group in
which he is an active member. Activities in various support and political
organizations help him feel he is contributing to his own well-being and that of
other AIDS victims.
The Victim
The victim makes excessive demands on other people and seems to be
extremely dependent. Control is relinquished to other people, who then are
expected to share the anxiety and take charge. Even though she
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care workers and for family members. If a patient's style of dealing with AIDS
is respected, it can enhance patient care in several ways. By permitting the
patient some autonomy and control over how therapy is administered,
cooperation between patient and concerned others is facilitated. This may
operate to improve treatment outcomes. It
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When AIDS afflicts a family member or a loved one, people must stand by and
watch the inroads of the illness. Their support is crucial, even though they may
feel quite helpless. In the absence of effective cures, social and family help is
all-important. It is the homosexual with AIDS, however,
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who is most frequently beset with family problems. Some families may have
become reconciled to the sexual orientation of a homosexual relative, but the
diagnosis of AIDS seems to open old scars.
The deterioration, physical and emotional, that AIDS causes may lead to
regressive behaviors on the part of the patient and the family. A frequent
consequence of AIDS is the reemergence of parents as caregivers to their ill
adult child. In their pain, parents may search for something or someone to
blame. They may blame the sick person for choosing a life that entailed so
much risk. If drug use, promiscuity, or prostitution are involved, family
members may feel angry and humiliated. They may blame themselves for being
poor parents who somehow contributed to the habits that caused the illness.
AIDS differs from other illnesses in that it activates problems that were once
pushed aside. Relationships between homosexual persons and their families
may have been troubled for years before the onset of AIDS (O'Donnell &
Bernier, 1990). Even when parents did their best to be accepting, there may
have been little contact between them and a homosexual son or a drugaddicted daughter.
The AIDS diagnosis may prove to be a catalyst that does not greatly change
ingrained parental attitudes, but may change parental behavior. Parental
reactions to an adult child with AIDS are varied. Kubler-Ross (1987) stated
that between 1984 and 1986 about half the mothers of AIDS-stricken sons
actively cared for them and a third of the fathers in her study were involved to
some degree.
Fathers seem to have more difficulty adjusting to homosexuality in a son than
mothers do. Difficulties may arise between parents of a homosexual son or
daughter when the father and the mother do not react in the same way.
Difficulties develop between the parents when one is more accepting than the
other, or when one expresses opinion that the other parent does not wish to
hear. It is not uncommon for parents to become estranged from each other
upon learning of their child's homosexuality. Parents who had looked forward
to welcoming grandchildren are dismayed to realize that this is unlikely to
happen. A proper therapeutic stance is to help these distraught parents realize
that each experiences stress in different ways and uses different coping
methods. Parents may have managed to reach a state of equilibrium after
finding out about a son or daughter's homosexuality, only to be propelled into
crisis when an AIDS diagnosis is made. The parents may need counseling so
that they do not turn away from each other and from their ill child.
There are several community support groups to which parents, relatives, and
close friends may be referred, many of which can be reached through local
phone directories or health agencies. Another source is the Federation of
Parents and Friends of Lesbians and Gays, Inc., P.O. Box 27605, Washington
D.C. 20038. Federation has branches across the country. For advice, phone:
(202) 638-4200 or hot line: (800) 4-FAMILY.
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easier to become reconciled to her son than to his sexual partner. Occasionally,
the mother of an individual with AIDS will see her son's lover as a rival for her
ill son's affection. Their subsequent actions may then replicate the competing
attitude of a hostile parent toward a son-in-law or daughter-in-law. Unless the
dissension can be minimized, the competitive atmosphere will add to the
turmoil of the
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household. Ideally, parents and other family members will rally and join with
their son's partner in caring for the ill person. When parents allow the lover to
share their grief and decisions, their own isolation is alleviated. As they learn to
know their son's lover, they gain more understanding of their dying son and for
the meaningful relationships in his life (Newman & Taylor, 1987).
AIDS and Survivors
The number of actual and projected deaths resulting from the AIDS epidemic
is overwhelming, especially in gay communities and in the creative arts such as
music, dance, theater, and design. This means that many individuals have
suffered multiple losses as colleagues, companions, and lovers have
succumbed. For some people, the epidemic has become a major catastrophe
(Lennon et al., 1990). Govani (1988) described the experience of people who
have lost two hundred people who were socially or professionally important to
them. The result is that, for many survivors, grief and mourning are unending
processes in which there is no time for recovery. Each death is met in the
context of the deaths that went before and fear of the deaths that are to
come. By the year 2000, over half a million AIDS-related deaths will have
occurred, and millions of people will have faced multiple losses.
In a study of male and female homosexuals who had confronted multiple losses
to AIDS, Cormack (1992) found that respondents monitored their reactions in
an effort to achieve a balance between extreme (dysfunctional) engagement
and extreme (dysfunctional) detachment. The balance is integrative, but it is
always fragile and tentative. Several respondents expressed fear of moving too
far in either direction of the continuum. In Cormack's (1992, p. 11) study, one
of them explained, "Detachment works well for me, but I have to monitor it
because if I become too detached, I become dysfunctional because I feel
unreal, out of touch with what's happening and not connected, and that
feeling can lead to depression."
Apparently, some survivors are able to protect themselves against
overinvolvement while remaining concerned and committed. Yet many of them
react to additional loss, real or anticipated, by shifting in the direction of
extreme disengagement or extreme attachment. Functional detachment was
obtained through behaviors such as getting away on weekends or trying to
have a life that was not centered on AIDS. Cognitive mechanisms such as
meditating, praying, or consciously distracting oneself were also used.
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quoted one survivor who was struggling to formulate new goals and relinquish
old ones. "What matters is whether we have enough presence of mind to
notice the birds are singing and the sun is shining." Extreme involvement and
extreme detachment may arrive in the aftermath of unresolved grief.
Counseling should be directed to helping survivors find a middle ground where
they
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can surrender those who have died without cutting themselves off from
meaningful friends and support networks.
It is almost impossible to accelerate a grief process, but avoiding grief has
negative effects. Traditionally, people in the United States have been urged to
be "strong" instead of mourning openly. Yet survivors need to be able to weep,
find other people who have undergone similar losses, and talk about those who
have died. Rosenthal (1992) stated that reminiscing and exchanging memories
does not drain survivors, but replenishes them. In Support group, survivors
may be asked to bring some article that reminds them of their loss, display the
article, and talk about its significance to the one who has died.
In bereavement groups, the ritualistic reading of the names of the dead can
comfort survivors-witness the cathartic effect on families and surviving
comrades produced simply by reciting the names of servicepersons lost in the
Vietnam combat. Occasionally, in groups organized for people who have lost
loved ones to AIDS, reading the names of the dead is accompanied by the
steady beating of a drum (Rosenthal, 1992). These interventions are based on
the idea that shared sorrow is diminished. Even though these strategies may
seem an ordeal at the time, they leave the participants with a sense of release
and greater willingness to get on with their own lives.
AIDS and the Health Care Professional
In the early 1980s, patients with AIDS were not often recognized in health
facilities. Now, persons working in the health care professions can no longer
ignore or avoid the large number of people with AIDS being cared for in clinics,
general hospitals, hospices, and psychiatric centers. For a time, AIDS patients
were identified as people who lived outside the mainstream of society. This
early stereotype, plus the absence of definitive treatment or cure, has made
the care of AIDS patients very difficult. Wallach (1989) reports that physicians,
nurses, and other caregivers are not immune to anxiety about homosexuality,
and the AIDS epidemic exacerbates this anxiety. Fear of contagion causes
some members of health care professions to avoid or neglect persons suffering
from AIDS. Wallach found that minority health caregivers are more troubled by
the contagiousness of AIDS, more distrustful of information regarding safety
measures, and more uneasy when caring for homosexual patients. Granted
that this was a limited sample, the data suggest a need for educational
programs especially designed for health care professionals educated abroad
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AIDS. They must also identify in themselves any limitations or negativisms that
might be detrimental to infected persons. Leukefeld (1989) lists a number of
useful considerations for clinicians and practitioners.
It is possible to establish rewarding and mutually beneficial relationships with
persons who have AIDS.
Working with an AIDS patient is very demanding and burnout is a constant
threat. Access to educational programs, professional support groups, and AIDS
network groups can be a sustaining force.
Practitioners and clinicians should avoid excessive self-sacrifice and martyrdom.
They should attend to their own needs and maintain interests in activities and
recreation unconnected to their professional lives.
It is important to examine one's feelings about AIDS, death, and dying.
Practitioners and clinicians should expect to have feelings of despair and futility
at times, even as they try to deal realistically with the AIDS-stricken person
and the family.
No health care professional should willingly become the sole care provider of a
person with AIDS. Tasks and responsibilities should be distributed and shared
to avoid feelings of engulfment and/or isolation.
Practitioners and clinicians should take an active part in reducing prejudice and
ignorance about AIDS. They should strive to eradicate boundaries regarding
the allocation and distribution of services to persons with AIDS.
People in the health care system face problems in managing HIV-positive and
AIDS-stricken persons who refuse testing or continue to engage in high-risk
activities. Some states have passed "noncompliant carrier statutes" aimed at
safeguarding the public. Unlike statutes that mandate reporting activities such
as child abuse, these regulations make reporting discretionary. As a
consequence, a clinical and legal impasse exists (Carlson et al., 1989).
Sometimes the rights of patients seem to conflict with those of the health care
professional. Hill (1991) describes an incident in which a nurse suffered a
needle prick while treating a patient in a general hospital. The patient had not
been tested for HIV and refused to submit to testing. According to the Centers
for Disease Control, the risk of contracting HIV from one needle-stick exposure
to contaminated blood is 0.03 percent. Since 1981, forty health care workers
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found to be HIV positive. Follow-up showed the nurse to be HIV negative after
one year, but she no longer works in the clinical setting and still feels that her
own rights were considered secondary to patients' rights of confidentiality.
Counseling the Health Care Professional
There is a curious inconsistency in people's attitudes toward those infected
with the AIDS virus. In the past, infectious diseases such as scarlet fever and
diphtheria caused entire households to be quarantined. Not many years ago,
persons with active tuberculosis could be confined forcibly during infectious
stages of their disease. In some respects, the stigma surrounding AIDS has
operated to the detriment of persons caring for these patients, who may be
placing themselves at risk when the HIV status of a patient is unknown. There
is an apparent conflict between patient advocacy and the need to protect
dedicated members of the health care profession.
Shubin (1989) stated that health care providers who have put their fears aside
in order to care for AIDS patients sometimes find that their colleagues have
trouble relating to them. Even though the colleagues know that AIDS cannot
be transmitted through casual contact, they distance themselves from
caregivers working with AIDS patients. The families of caregivers who have
chosen to work with AIDS patients may make the burden greater. Some
families repeatedly express worry that the caregivers may contract AIDS. They
also are concerned about protecting themselves. The families warn caregivers
to shower before coming home and not to bring home any garment that was
worn while attending to patients. All these reactions mean that many
caregivers working with AIDS patients must turn to one another for support.
Some units offer organized support groups for these health care workers, but
Shubin (1989) thought that it is the environment of the unit that is all
important. Like everyone else, health care workers have different ways of
dealing with stress. For some, a support group is helpful, but not for all. An
important consideration, then, is that attending a support group is optional.
Understanding and showing empathy from co-workers or supervisors on a dayto-day basis may make the difference between burnout and the ability to
continue in these demanding clinical settings. Working with people one can
trust, with whom one can weep for the AIDS victims and rage against their
fate, is an outlet for many health care workers in this field.
When a general hospital in San Francisco opened an AIDS unit in 1983, the
staff began to keep a log or journal containing the names of all the patients
who had been cared for there before dying. Far from being
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morbid, the log was a way of remembering them. Victims continued their
personhood and they did not become mere numbers. The staff reports that the
names and the recollections they invoke is a solace for the staff.
People who take care of AIDS patients derive some emotional satisfaction, or
else they could not continue. Many caregivers reach what Erikson (1963) called
a state of ''ego integrity" that overcomes despair. From a philosophical
standpoint, these caregivers learn to accept death as an integral part of the life
cycle. From a professional standpoint, they learn to concentrate on comforting
the patients, not curing them. This might mean dealing with opportunistic
infections such as pneumonia or meningitis, using nutritional supplements to
delay or reverse declines in immune functioning as the infection progresses
(Keithley et al., 1992), or welcoming the visits of a friend or lover whose
companionship eases the patient's suffering.
Health care professionals who work mostly with AIDS patients have developed
the following commandments (adapted from Shubin, 1989) for bedside
caregivers and other staff members:
Learn to say no to some of the requests made of you. Taking care of yourself is
the first lesson AIDS caregivers must learn. In addition to clinical
responsibilities, these caregivers are in demand as teachers and lecturers. Be
selective in choosing these activities.
Accept, intellectually and emotionally, what your limits are. Set a pace that is
comfortable and will not push you to the breaking point, especially in the
clinical setting.
Realize that some patients will not always be compliant or accept your
suggestions. Try to understand the underlying reasons without unduly blaming
yourself.
Do not make AIDS the center of your life. Take time off without feeling guilty.
Take advantage of all sources of support-family, friends, colleagues, and
groups.
Be proud of the work you are doing. It is a testimony to your courage and
professionalism.
A Citizens Commission on AIDS, operating in New York City and northern New
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Company policies should be based on the fact that HIV cannot be transmitted
through ordinary contact in the workplace.
Employers should provide accurate, up to date information on risk-reducing
behavior.
Employers should protect the confidentiality of an employee's medical status.
HIV screening should not be a required element of pre-employment or routine
medical examinations.
In work settings such as clinics or hospitals where there is risk of HIV
exposure, employers should provide adequate instruction and equipment to
make sure that infection control procedures are instituted and maintained.
Professional and family members caring for persons with AIDS need to know
that there is danger of infection from exposure to body fluids, and should be
given extensive instructions on avoiding transmission. The American Red Cross
maintains an Office of HIV/AIDS Education, 1709 New York Avenue N.W.,
Washington, D.C. 20006, phone: (202) 434-4074. Local American Red Cross
chapters may also be contacted.
Clinical Example: High-Risk Behavior and Negativism in an HIV-Positive Male
Kenny Johnson, a twenty-two-year-old heroin user, tested HIV positive, although he
was symptom-free. He learned this when he was tested in a community-based drug
program. The testing center guaranteed anonymity. Very little post-test counseling
was given because Kenny was already participating in a drug rehabilitation program.
He was strongly advised to disclose the results of his test to counselors in the drug
program, but the testing center kept its promise of confidentiality.
Kenny did not inform the drug program staff immediately, even though he was very
upset by the test results. Two of his close friends had recently died of AIDS; Kenny
was convinced that he would meet the same fate. He tried to commit suicide by
overdosing on heroin. After lying unconscious in an alleyway, police found Kenny
and took him to a general hospital in the city. Here, staff members found Kenny to
be sullen and angry. He resented the efforts to save his life since he was going to
die from AIDS anyway. Because he had been rescued only to face a worse death,
Kenny threatened to take as many people with him as possible. He insisted that
infecting other people was the best way to get back at whoever had infected him.
He persistently endangered disease control precautions while in the hospital. He
refused to remain in the hospital or to accept a residential drug
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rehabilitation program. Hospital physicians sought legal advice, but were told that
Kenny had the right to leave the hospital without medical authorization if he chose.
The possibility of involuntary psychiatric commitment was explored, but the
regulations in this area were even more stringent. Hospital staff had learned that
Kenny was a bisexual who often engaged in prostitution to obtain money for drugs.
Social workers persuaded Kenny to go to a halfway house where he would receive
some supervision and his behavior could be monitored. No suitable facility in the city
was willing to accept Kenny because he would not agree to remain drug-free and
sexually inactive. Kenny had a sister living in the neighborhood who had visited him
a few times while he was hospitalized. Family meetings were arranged in the hope
that Kenny could live with his sister and her husband. At first she was willing, but
when she learned that Kenny was HIV positive, she reported that her husband and
her mother-in-law would not let Kenny in the house. She also said that they insisted
she not see her brother again. At this point, Kenny signed himself out of the hospital
to live with a couple who were known drug users. Kenny and his friends had
previously attended an outpatient drug program where they were known to share
syringes and needles. This was a methadone maintenance program from which
Kenny and his friends had dropped out as their methadone dosage was reduced.
Critical Guidelines
Following state regulations concerning HIV-positive status, hospital personnel
notified the health department. Public health officials and community nurses tried
unsuccessfully to discover where Kenny and his friends were living. Twice they were
given addresses, only to find that the group had moved elsewhere. Although health
care workers were concerned that Kenny would continue his drug habits and engage
in sexual prostitution, there was little more that they could do. In all probability,
Kenny's friends were HIV positive, but testing could not be arranged unless their
whereabouts were known. Some ten months after Kenny disappeared from sight, an
emergency ambulance brought him to the hospital. By this time he was emaciated
and had oral lesions in his mouth and throat. It was clinically apparent that Kenny
showed signs of ARC. This time he did not respond to medical treatment. The
coroner determined that Kenny had died of an intentional or unintentional heroin
overdose.
Kenny's case exemplifies the multiple problems due to his negativism, and
indifference to his own welfare and that of others. Aftercare programs considered
Kenny unsuitable because he was not only HIV positive, but he was also an
unrehabilitated heroin user. Staff members in community programs refused to
accept him because they wished to protect their vulnerable clientele. Kenny's sister
led a stable life, but withdrew her offer of shelter when her own family expressed
opposition.
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This case illustrates the difficulties in dealing with HIV-infected persons under the
current ambiguous regulations. Although official policies recommended informing
others of Kenny's HIV status, there was no clear policy to enforce disclosure. Neither
were there any regulations insisting on Kenny's compliance. The months when he
dropped from sight were a time when he could have infected many other people.
Health care personnel tried to convince Kenny of his obligations to the public, but
balanced this against his right to confidentiality. This meant that no one was told of
Kenny's test results without his knowledge and consent. Clearly, state regulations
and community resources were inadequate in this situation.
Summary
The effects of the AIDS-causing virus constitute the most formidable public
health problem of the twentieth century. No longer limited to any one group,
nation, or gender, the AIDS epidemic has spread worldwide within the last
decade. Since no dependable cure is currently available, control of the
epidemic depends largely on education and prevention. Infection is not
transmitted through casual contact, but can be spread through exposure to
body fluids of infected persons.
The virus has a latency period of up to ten years. Individuals who are
seropositive harbor the virus, even though they may be symptom-free. These
individuals are a hazard to others if they engage in unprotected sexual
transactions. As the infection progresses, the immune system is depressed and
individuals develop the AIDS ARC. This is marked by symptoms such as fever,
weight loss, enlarged lymph glands, and recurrent bouts of opportunistic
infections. A large percentage of individuals (30 percent) eventually develop
AIDS. This disease is progressively debilitating, leading to intractable illnesses,
culminating in death.
AIDS is both a chronic and a terminal disease. This means that AIDS-stricken
individuals undergo prolonged suffering and disability. Friends and family
members must watch helplessly as patients grow weaker. Patients require
extensive treatment and compassion, and so do the persons who are involved
in their care. This includes family, friends, volunteers, and professional health
care workers. Many of these people have endured multiple losses as infected
persons succumb to AIDS.
Many victims of the AIDS epidemic are young people in the prime of life. Their
untimely deaths compound the difficulties of persons involved in their care.
Page 368
with the AIDS epidemic constantly deal with depletion because of excessive
demands made upon them. Many of these workers benefit from organized
programs, but a large number have devised their own methods of helping
themselves and their colleagues.
The first cases of AIDS were identified in the United States in 1981, although
the virus was probably present in the population before that time. Statistics
and other data on AIDS and HIV are continually revised as researchers
continue their search for improved treatment and preventive measures. In the
absence of definitive information, the only recourse is emphasis on education,
especially among members of high-risk groups and among the large numbers
of people, infected and uninfected, who have been damaged by the rampant
AIDS epidemic.
References
American Medical Association. "Prevention and Control of Acquired
Immunodeficiency Syndrome: An Interim Report. JAMA 258(1987): 20972103.
American Psychiatric Association. "Aids Policy: Confidentiality and Exposure."
Psychiatric News January 5, 1988, p. 27.
Booth, W. "CDC Paints a Picture of HIV Infection in the United States" Science
239(1988): 253.
Carlson, G.A., M. Greeman, and T.A. McClelland. "Management of HIV Positive
Psychiatric Patients Who Fail to Reduce High Risk Behavior." Hospital and
Community Psychiatry 40(1989): 511-514.
Centers for Disease Control. "Public Health Service Guidelines for Counseling
and Antibody Testing to Prevent HIV Infection and AIDS." Morbidity and
Mortality Weekly Report 36(1987): 509-515.
Chaches, E. "Women and Children with AIDS." In Responding to AIDS:
Psychosocial Initiatives, edited by C.G. Leukefeld and M. Fimbres. Silver
Springs, Maryland: National Association of Social Workers, 1987.
Cormack, B.J. "Balancing Engagement/Detachment in AIDS Related Multiple
Losses." Image 24(1992): 9-14.
Curran, J.W., H.W. Jaffe, A.M. Hardy, et al. "Epidemiology of HIV Infection and
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Keithley, J.K., J.M. Zeller, D.J. Szeluga, and P.A. Urbanski. "Nutritional
Alterations in Persons with HIV Infection." Image 24(1992): 183-189.
Kubler-Ross, E. AIDS: The Ultimate Challenge. New York: Macmillan, 1987.
Lennon, M.C., J.L. Martin, and L. Dean. "The Influence of Social Support on
AIDS Related Grief Reactions among Gay Men." Social Science and Medicine
31(1990): 477-184.
Leukefeld, C.G. "Psychosocial Issues in Dealing with AIDS." Hospital and
Community Psychiatry 40(1989): 454-455.
Mishel, M. "The Measurement of Uncertainty in Illness." Nursing Research
30(1981): 258-263.
Mishel, M., and C.J. Braden. "Finding Meaning: Antecedents of Uncertainty in
Illness." Nursing Research 37(1988): 98-103.
Mishel, M., and D. Sorenson. "Uncertainty in Gynecological Cancer: The
Mediating Functions of Mastery and Coping." Nursing Research 40(1991): 167171.
Newman, B.A., and E.H. Taylor. "The Family and AIDS." In Responding to
AIDS: Psychosocial Initiatives, edited by C.G. Leukefeld and M. Fimbres. Silver
Springs, Maryland: National Association of Social Workers, 1987.
Noble, B.P. "AIDS Awareness Goes to the Office." The New York Times
December 6, 1992, F25.
O'Donnell, T.G., and S.L. Bernier. "Parents as Caregivers: When a Son Has
AIDS." Journal of Psychosocial Nursing 28(1990): 14-17.
Perry, S.W., and J.C. Markowitz. "Counseling for HIV Testing." Hospital and
Community Psychiatry 39(1988): 731-739.
Ragsdale, D., J.A. Kotarba, and J.R. Morrow. "Quality of Life of Hospitalized
Patients with AIDS." Image 24(1992): 259-265.
Regan-Kubinski, M., and N. Sharts-Engel. "The HIV Infected Woman: Illness
Cognition Assessment." Journal of Psychosocial Nursing 30(1992): 11-15.
Rosenthal, E. "Struggling to Cope with Losses in AIDS Rips Relationships
Apart." The New York Times December 6, 1992, A1.
Page 371
PART FIVE
ATYPICAL CRISIS
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15
Post-traumatic Stress Reactions:
War and Rape
Nothing is calmer, more orderly than death. Chaos is not very nice; loving chaos is
dangerous, very very dangerous. You can see that even in the streets these days; it
might be the end of us all, this love of chaos. But then life is always more frightening,
more dangerous than death is.
Gabriella De Ferrari
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among veterans of the Vietnam conflict ranged from a half million to one and a
half million men and women who served (Walker, 1982).
Although the diagnosis of PTSD has been expanded to include not only combat
veterans, but rape victims, battered women, and other victims of stress and
trauma, there is some disagreement among clinicians concerning the
syndrome. A number of professionals believe that persons with PTSD have preexisting problems that stress exacerbated. This has contributed to the
problems that veterans encountered in the 1970s when the diagnosis had not
yet been officially recognized. However, as knowledge of the Vietnam
experience penetrated professional circles, the syndrome began to receive
proper attention. Moreover, knowledge of various aspects of PTSD broadened
public and professional awareness of the adverse consequences that may
follow any severe stress or trauma.
In addition to defining PTSD, the DSM-III-R lists the following five diagnostic
criteria for PTSD (adapted from the American Psychiatric Association, 1987).
1. Exposure to a traumatic event or experience outside the usual range of
human experience.
2. Reliving or reexperiencing the event in various ways, such as painful
memories, intrusive and repetitious thoughts, dreams, nightmares, flashbacks,
chronic anxiety, and dissociative episodes.
3. Persistent avoidance of stimuli associated with the traumatic event.
4. Persistent symptoms of arousal or reaction to stimuli associated with the
traumatic event or experience.
5. Duration of symptomatology of at least one month, occurring at least six
months after the traumatic event or experience.
The DSM-III-R indicates that, besides reexperiencing the trauma and the
psychic numbing, at least two of the following symptoms must be present:
hyperalertness, sleep disturbance, survivor guilt, impaired memory, difficulty in
concentrating, and avoidance of activities that are reminiscent of the traumatic
experience. Anxiety and depression, often accompanied by suicide ideation, are
also frequent, along with low tolerance of frustration and explosiveness.
Veterans sometimes reported idiosyncratic reactions. For instance, one veteran
found that any red substance, such as tomato sauce, made him think of blood
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diagnosis is chronic PTSD. If onset occurs at least six months after the trauma,
delayed PTSD is the proper diagnosis. Impairment can run the gamut from
mild disruption of one's functioning to severe disruption in which almost every
aspect of the person's life can be affected.
The symptom pattern in reaction to the trauma is quite striking. First, there is a
tendency to relive the event in one form or another. The reliving may be
through nightmares, intrusive thoughts, and/or almost obsessive ruminations.
Flashbacks, the feeling of "being there again," and of reliving the event, set off
by some seemingly neutral stimuli in the environment, are also a common
phenomenon, especially among combat veterans. As an example, a veteran
may notice similarities in terrain while on a camping trip with his family that
take his thoughts and feelings too realistically back to a setting in Vietnam,
bringing about a fast curtailment to a much-looked-forward-to vacation.
Trauma involves a range of experiences and feelings that includes fear, panic,
guilt, anger, and pain, both physical and emotional. When one is traumatized,
the normal inclination is to withdraw and/or escape both physically and
emotionally. Children who badly burn their hands on an oven door will put
some distance between themselves and the stove, give it a wide berth in the
future, and may even develop a phobia toward the punishing object. People
with PTSD have been burned; but it is their psyches, not their flesh, that is
scarred. Like the burned children, they too would like to isolate themselves
from the event and its emotional overlay; but the experience, with its many
emotions and associations, is so complex that they cannot dissociate
themselves from it without shutting down a good part of their emotional lives.
If you no longer feel anything deeply, the unconscious logic goes, and you
cannot be so deeply hurt again. Interpersonal relations can be profoundly
affected. The things that the veteran once enjoyed hold no pleasure any
longer, and the veteran's overall affect can appear blunted, even schizophrenic
in extreme cases. It is important to note, however, that PTSD is classified as an
anxiety disorder, not a psychosis.
The Diagnostic Dilemma
According to Jellenek and Williams (1984), the most frequent PTSD
complication is substance abuse. This is particularly true of the Vietnam
veteran partly because American military authorities dispensed various drugs.
Amphetamines were used to stay awake; phenothiazines and other
tranquilizers were used in combat for the first time. Alcohol was widely used,
and even distributed to soldiers following an action. Marijuana was frequently
used to reduce fear and stress. With this history, it was not surprising for
Vietnam veterans to continue to use drugs after returning
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home. Newman (1987) cited the tendency of veterans with PTSD to medicate
themselves for sleep problems, chronic anxiety, and harrowing recollections.
Unfortunately, dependence on alcohol and other drugs caused veterans to be
treated solely for substance abuse, while deeper problems were overlooked.
It is true that the PTSD symptoms may resemble those of other disorders.
Sometimes PTSD is overlooked entirely; sometimes it is considered to be a
secondary, rather than a primary, problem. Newman (1987) reported that the
most frequent misdiagnosis of PTSD is personality disorder. This is probably a
reflection of the traumatized veteran's inclination to distrust and antagonize
others, particularly those in authority. The second most frequent misdiagnosis
is psychotic disorder, usually paranoid schizophrenia.
Depression with a high risk of suicide has been identified as the most common
symptom of PTSD. Other symptoms include poor impulse control, antisocial
behavior, interpersonal distancing, and potential for violence. It was not until
1980 that the Veterans Administration authorized compensation and other
benefits for persons afflicted with PTSD. Even then, applicants had to meet all
the DSM criteria before compensation was paid. Blair and Hildreth (1991, p.
15) wrote,
''The intensity of resistance and anger toward these patients by professionals can be
most startling. Programs and plans of care are fraught with personal control issues,
bias, and issues of pathological staff group dynamics."
The media have done much to sensitize the public and professionals to the
rigors of the Vietnam combat experience. However, there continues to be some
resistance to the validity of this diagnosis. Malingering is the term clinicians
sometimes apply to these patients. Much of the resistance is attributable to the
misperception that war wounds must be visible and physiological. Yet combatrelated breakdowns have victimized soldiers in many different wars. In most
instances, only the name of the breakdown was changed, as shown in Table
15-1. Percentages refer to those lost to further combat due to psychological
trauma.
Sometimes it is difficult to discern from a veteran's history whether his
condition is chronic or delayed in nature. Often, with the abatement of
symptoms brought on by the exuberance of returning home, chronic symptoms
may appear to be delayed in onset. At other times, there really is no
symptomatology until several months or years post-trauma. In either case,
most of what follows applies, and this author will use the term delayed PTSD to
encompass both categories. This simplification also makes sense from a
sociological point of view, since the word delayed may refer more to the
veteran and society recognizing the problem later than to the appearance of
the symptoms.
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TABLE 15-1 Percentage of U.S. Armed Forces Lost to Service
Due to Combat-Related Psychiatric Disability
Conflict
Percentage Affected
Terminology
World
8 percent of armed forces
Shell shock
War I
War neurosis
World
37 percent of armed forces
Battle fatigue
War II
Combat fatigue
Korean 25 percent in first years (later
Post-combat
War
under 37 percent)
psychiatric disorder
Vietnam
Post-traumatic stress
12.6 percent of armed forces
War
disorder
Source: Adapted from Rundell et al. (1989); Blair and Hildreth
(1991).
A Three-factor Theory
In trying to understand the Vietnam veteran with delayed PTSD, a holistic
approach to the problem seems most helpful. When examining the effects of a
traumatic event, it is important to look at the individual and whatever strengths
or weaknesses he brings with him to the situation, at the nature of the
stressor(s), as well as at the social context within which the traumatic event
occurs.
The Warrior
Of great significance is the fact that the Vietnam soldier was between
seventeen and twenty-five years of age, with an average age of less than
twenty years (19.2). Among others, Wilson (1978) presented demographic
data on the veteran, but with two and a half to four million men passing
through Southeast Asia, it is difficult to speak of the average soldier and his
strengths and weaknesses except in the most general of terms. It is in the
most general of commonalities that a very significant factor emerges.
The average Vietnam veteran was in his late adolescence or early adulthood.
In his theory of psychosocial development, Erikson (1968) explained that
various stages in one's life required the resolution of specific key conflicts. For
the adolescent or young adult, the task is to establish his sense of self, his
identity, or else run the risk of role confusion and loss of self. That warrior of
Vietnam was a young man in the midst of his own very important identity
crisis.
One need only look back to one's late teens and early twenties to remember
what it was like. Those of us who are products of a liberal arts education can
recall our college days and the existential crises we experi-
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enced. Interacting with classmates whose beliefs and backgrounds were often
quite different from our own; learning about the diverse, and often
contradictory, philosophical, political, and theological systems of the world;
trying to figure out who we were, what we wanted from life, where we were
going. These were the important tasks we were undertaking, and their
successful resolutions meant more than any college degree received in the
process. Those young people who entered the job market after high school
faced the same questions, only the answers had to be sought in the context of
the marketplace. In either case, society stepped back, allowed youths to
question and rebel, to try their wings, and to pull their lives together.
There was no psychological moratorium for the Vietnam veteran during which
he could find himself. On the contrary, the military gave the young draftee
training, camaraderie, and an imposed identity as a warrior. Unfortunately, he
was ill-prepared for the brutality of a guerrilla war; so that even his identity as
a warrior was ultimately severely shaken (Wilson, 1978). He returned home a
loser in the minds of most Americans, and often in his own mind. More
importantly, the veteran came face to face with destruction and death,
according to Caputo (1977, p. xiii), "at an age when it is common to think of
oneself as immortal." At the same time, the veteran had to confront a dark side
of himself that most of us never need to see, a person who could kill and who
sometimes even enjoyed doing it. How does one fit these primordial bits of
information into a unified concept of self? Not only does combat delay identity
integration, it also supplies the person with new data with which he has never
been adequately prepared to deal. For many Vietnam veterans, the work of
Erikson's fifth stage (resolving the identity vs. role diffusion conflict) has never
been successfully completed.
For the veteran who did seek help early, or even within the last couple of
years, through the Veterans Administration, it is not uncommon to find only
meager reference to his military service in the clinical history, such as "Veteran
served in Vietnam from this date to that, and was discharged on such and
such a date." The clinical worker often asked nothing about what the soldier
actually experienced there, and the veteran, who was often guarded and
reluctant to talk about his feelings, was in no hurry to volunteer that
information. In mental health facilities outside of the Veterans Administration,
it is common to find no reference at all to the military history of the individual.
Therefore, what typically follows in the clinical assessment process should not
be surprising. The veteran speaks of his distrust for people in general. He gives
an erratic job history marked by confrontations with authority. He may be
misusing, or has in the past abused, alcohol or drugs. His history includes
violent episodes and possible arrests. When asked, and he usually is asked, if
he ever hears things that others don't
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hear, or sees things that others don't see, he may answer "yes" to both and
get too choked up or defensive to explain what are essentially flashback (not
psychotic hallucinatory) experiences. He may give his presenting problem as
depression or suicide ideation. Put this symptom picture together, and one of
two diagnoses commonly will appear: character disorder or schizophrenia
(paranoid, schizoaffective, or undifferentiated, depending on what symptom is
most prevalent at intake).
If PTSD is misdiagnosed as schizophrenia, the treatment of choice tends to be
medication, something to which many veterans take exception: one veteran
being treated in a VA facility complained, "They gave me one pill in Vietnam
when I went out on patrol to get me up, and another pill when I came back
from patrol to get me down. I don't want anymore of their goddamn pills." If
the veteran with PTSD is misdiagnosed as an antisocial personality, there really
is no treatment for him, since sociopaths are not readily amenable to therapy
and are often considered unpleasant folks with whom to deal. In either case,
there is a man whose real problem has gone undetected and untreated, and
whose self-concept as well as his reputation have been irreparably damaged by
a haunting misdiagnosis. The misdiagnosis is haunting. The veteran has to deal
with the fact that "the system" has labeled him "crazy" or sociopathic when he
knows that he is neither. Moreover, trying to get compensation for a veteran in
the Veterans Administration with delayed PTSD, especially if he has been
misdiagnosed at any point in the past, can be a formidable task.
In many cases, the veteran's worst enemy is himself. One veteran who lost
control of his temper went home and shaved his head for reasons he could not
explain, but his behavior seemed an obvious act of self-punishment. Unable to
work because of his PTSD symptoms, he refused to apply for public assistance,
claiming it was demeaning and not worth the hassle. At the same time, he was
living on the streets or off his family, and losing all respect for himself for doing
so. His approach to life had become one of passive submission, marked by
general underassertiveness with occasional explosive episodes. Such a pattern
leads to more guilt, depression, and a self-defeating cycle of pity and more
self-punishment.
Many veterans talk angrily of how they are portrayed in the media or thought
of in the job market as "time bombs" waiting to explode. Ironically, this is
precisely how many Vietnam veterans look on themselves. Their concern about
losing control and committing violent acts is a strong emotional issue in group
psychology. Many will avoid every situation where the potential for violence is
even remotely present. A co-worker's hostility led one veteran to quit a wellpaying job for fear of losing control and killing the man. For the angry veteran
concerned with his potential to hurt others, a dangerous psychodynamic
mechanism can occur: the rage may turn inward on the veteran in the form of
suicide ideation and
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takes one makes are often transmuted directly into others' pain; there is sometimes
no way to undo that pain-the dead remain dead, the maimed are forever maimed,
and there is no way to deny one's responsibility or culpability, for those mistakes are
written, forever as if in fire, in others' flesh (p. 74).
All warriors in history have had to deal with these undeniable truths and come
to terms with them in their own way before going on with their lives. In many
cases, the trauma of the events themselves as well as the emotional burden of
accepting responsibility for them are lessened to some degree by the
understanding and welcome extended to the returning warrior from his loved
ones and by his society. As a participant in a "just" war with a "noble" cause,
the returning soldier can more easily resolve the dissonance the combat
experience and its legacy created.
For the two and a half to four million veterans who served in Vietnam,
especially for the more than one million who saw combat, conditions needed to
deal effectively with their experiences were noticeably absent. The nature of
the warrior, the unique features of the Vietnam conflict, and the ambivalent
attitude of America toward both created conditions that have impaired the
readjustment of tens of thousands of Americans.
The reported incidence of acute combat disorders in Vietnam was quite low, as
were all psychiatric casualties for that conflict (Bourne, 1970). The specific
reasons for this misleading statistic will be discussed shortly. However, the
number of chronic and delayed reactions being identified was overwhelming at
times, and Egendorf et al. (1981) suggested that half of all Vietnam veterans
have significant psychological problems related to their war experiences.
As part of the plan to prevent psychiatric casualties, twelve-month tours of
duty were the general rule in Vietnam, interspersed with frequent rest and
relaxation (R & R). When a man's date of expected return from overseas
service (DEROS) arrived, he simply left his unit, only to be replaced by a new
body. People came and went as individuals, wreaking havoc with unit
cohesiveness and morale. It also led to what Wilson (1980) called the "survivor
mentality," in which the goal of a veteran's war involvement was not to win the
war, but rather to survive until his DEROS arrived.
Knowing he had only twelve months to serve "in country" and that then he
would be recalled home seems to have been a crucial factor in producing the
low psychological casualty rate figures. If a man is involved in a war for the
duration, as was the case in World War II, psychological problems might be
ignored or repressed for a while but eventually become unignorable. If, on the
other hand, the soldier can see a light at the end of a twelve-month tunnel, he
is in a better position to
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hold himself together, get his honorable discharge, and naively believe he can
go home and leave the war behind.
In Vietnam, it was as easy to obtain drugs as cigarettes; and anyone with
military experience knows of the availability and low cost of alcohol. Many
veterans under stress medicated themselves with whatever substance was
available. This medicating also had the effect of reducing the identification of
many psychiatric problems and lowering the casualty figures in this way. Men
with obvious alcohol and drug problems, and there were thousands, were
labeled as "character disorders" (not stress reactors) and administratively
discharged from the service as unsuitable for duty, presumably because of
preexisting problems. Kormos (1978, p. 21) suggested that an "epidemic of
combat reaction had been prevented only at the price of an epidemic of
character disorder." The military failed to realize that for many Vietnam vets,
drug abuse was simply the manifestation of a new form of psychopathology,
along with other symptomatic problems like widespread insubordination and
"fragging," the unhealthy and much-frowned-on policy of throwing hand
grenades at one's own comrades.
There was no debriefing for the returnee, no working through experiences on
the "slow boat ride home" with friends and comrades. As previously mentioned,
a soldier was pulled from his unit when his date of expected return from
overseas duty came up, and he might travel on a plane home with twenty
other individuals from twenty different units. One veteran related how angry
and guilty he felt on that plane, having "abandoned" his buddies whom he was
leaving behind.
The Social Context: The Homecoming
In their exhaustive study of Vietnam veterans, Egendorf et al. (1981) found
two pieces of data that relate to the impact of society on the adjustment of the
veteran. First, only combat veterans serving after 1968 have a higher incidence
of PTSD than their noncombat veteran peers. Secondly, during their first three
years back from "Nam," many veterans showed erratic changes in occupational
level, with a surprising downward trend during their second year home; this
phenomenon was shown to be unrelated to PTSD. Explanations for this
interesting data must be found by looking at Americans at home.
In 1968, America's attitude toward the war was really already bitter. The
antiwar groups became more vocal and more demonstrative in their protests,
and opposition to the war and its policies was growing, even within the
government structure. The man-child soldier who had lost his friends in combat
returned home to find he had lost many friends here also. To walk across a
college campus wearing a fatigue jacket invited
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taunts and ridicule, along with accusations of "baby killings" and atrocities. A
Vietnam veteran working in a local state-funded position trying to secure jobs
for other returning veterans met with off-the-record comments from potential
employers such as "Look, you seem to be all right, but these guys are too
unpredictable, we just can't take a chance with them." The Vietnam veteran
was seen and portrayed in the media, and still is in many areas, as a junkie, a
psychopath, a schizophrenic, or "an accident waiting to happen." Whereas the
door to jobs swung open for the returning World War II veteran, it was
slammed in the face of the Vietnam veteran. This rejection led many to deny
their veteran status on job applications and in conversations, and contributed
to their anger and their reality-based paranoia. When asked about the reason
for a noticeable limp acquired by courtesy of a Vietcong mortar barrage, one
veteran used to reply with a smile: "I injured it falling off my motorcycle on the
way to a peace demonstration in Washington."
In almost any conversation with a troubled Vietnam veteran, in every interview
and in any publication addressing the veteran's dilemma, the conversation
often turns to their homecoming, or, more precisely, their lack of a
homecoming. They speak of having no parade on their return, a remark that
leads to a great deal of misunderstanding and anger on the part of veterans of
other wars. It is quite commonplace to run into World War II or Korean
veterans who have no compassion for their Vietnam veteran brothers and who
look upon them as a bunch of overgrown crybabies. "I never had no parade," is
a common remark, "so what the hell is he crying about? He's no different."
What they fail to realize is that the word parade is simply a metaphor for things
like acceptance, support, and understanding. Vietnam veterans had enough
dissonance about the war and their role in it without becoming recipients of
any national frustration and guilt. Faced with outright rejection or just
disinterest, many chose to withdraw and to keep their feelings hidden.
The social factor in the evolution of PTSD cannot be downplayed. Egendorf et
al. (1981) offered statistics to show that veterans returning to close-knit
families and small towns showed significantly less symptomatology than did
their cohorts with little or poor family support in large urban areas. Social
support for the former group helped smooth the transition by creating a
supportive environment in which they could reintegrate their experiences.
There may be a temptation to cast the veteran in the role of victim or villain,
Page 384
A Vietnam veteran made this statement years after returning home, which
sums up his confusion and frustration with society:
My generation and my father's generation-we were brought up to love America, to
believe it was our responsibility to fight for America. Well, that's exactly what we
did. But when we came home, they rejected us-and we were only doing what they
wanted us to do and what we thought we had to do. And it hurts. ...
The Vietnam veteran's perceived need to fight for every benefit that the
government gives, the continued misdiagnosis of his problem, and the
government's denial of his requests for compensation in favor of simply putting
him on welfare-are all factors that deepen the hurt.
Counseling the Combat Veteran
Some years after the Vietnam War ended, it was evident that veterans were
having major readjustment problems. Many large numbers of them were
making no effort to find help within the Veterans Administration or even apply
for benefits, yet many of them were jobless, had marital problems, and had
police records of substance abuse or violent episodes. It was obvious that new
types of programs were needed. The organization known as Disabled American
Veterans established a program known as Vietnam Veterans Outreach
Program. Outreach centers were established in seventy cities across the
country. Shortly afterwards, Congress authorized funding for counseling
services for Vietnam veterans. Approximately ninety-one Veterans
Administration outreach centers are now in operation. Staffed largely by
Vietnam veterans and located where veterans live, not hidden away in large
medical centers, the congressionally funded program and the Disabled
Veterans program have been primary sources of counseling for veterans
suffering from PTSD. Often, the initial contact a veteran makes to an outreach
center is for employment or benefit advice. This ultimately leads to involvement
in support groups or referrals to a mental health center.
Rap Groups
Until Vietnam veterans' groups were available, a mental health counselor might
see a veteran in individual therapy with symptoms such as war-related
nightmares or impulse control. In trying to relate symptomatology to war
experiences, the counselor might meet evasion or silence. Veterans tended to
adopt a "you had to be there in order to understand" attitude that inhibited
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rationale for not talking about war experiences was removed when "rap"
groups were established in which all members were Vietnam veterans.
The veterans themselves organized many of these rap groups. As Williams
(1980, p. 45) explained, "Vietnam veterans are a group of survivors struggling
to return to the mainstream of society." Much of their struggle began on their
own, and later the Veterans Administration and Disabled American Veterans
sponsored them. Without the presence of a professional counselor or facilitator,
who may or may not be a veteran, the discussion in a rap group may not go
beyond ventilation and catharsis. As long as the professional is a person not
afraid to relate as a peer, to share and reveal his own experiences, he can
make constructive contributions to the group. With the addition of a
professional counselor or facilitator to the group, there is a significant shift from
a rap group to a psychotherapeutic group. Still, it is usual to retain the name
rap group since therapy implies mental illness, an interpretation of their
problems that veterans strongly resent.
Ziarnowski (1986) described important themes and issues arising in these
groups. The themes arise within the context of sharing war stories and include
guilt, anger, suicide ideation, distrust, lack of confidence, awareness of
mortality, problems of daily living, and fear of committing violent acts.
Unburdening these emotions has a cathartic effect, and the interest and
solicitude of group members goes a long way toward rebuilding feelings of
trust. For some veterans, this sharing of strong emotions and disclosing
troubling events has too powerful an impact, and it is not uncommon to lose
some members in the early stages of the group.
Gradually, other issues surface, still interspersed with war stories. Themes of
mortality and distrust occur and recur periodically. Veterans who have been
through combat and witnessed the death of buddies are stricken with their
own vulnerability. One veteran confided in a group that he never sat anywhere,
even in a fast food restaurant, unless he was near an exit with his back against
the wall. Hearing this, other veterans acknowledged the same behaviors. Some
seem to be forever on guard, looking over their shoulders, avoiding crowds,
and carrying or sleeping with weapons hidden for their protection against
unknown enemies.
Adjunctive Treatment
Group work seems to be the treatment of choice for most Vietnam veterans,
but some veterans are better suited for individual therapy, and others in a
group may require an individual session from time to time around a particular
problem. Flexibility is always the mark of a good therapist. Of utmost
importance is the realization that the veteran is part of a social network; if he is
malfunctioning, it affects many people directly and indirectly who are involved
with him.
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For these reasons, it seems wise to have a partner's group available whenever
a rap group is organized. The veterans' problems most directly affect the
women in their lives. Couples therapy, conjoint family therapy, and community
education programs-all are important alternatives and additions to the rap
group approach.
If cure means the absence of symptoms, there is some doubt that it can be
affected in delayed PTSD. Williams (1980) suggested making symptoms
manageable as a realistic goal of psychotherapy. He is a firm believer in any
pragmatic treatment program aimed at reducing or controlling the problems
and issues outlined. Williams (1980) suggested four major goals to therapy
with the Vietnam veteran: (1) help him control his anger, (2) help diminish his
guilt, (3) aid him in expressing his emotions, and (4) help him back into the
mainstream of society. To the last goal one might add, helping the veteran
accept responsibility for actions within the social context in which they
occurred, and encouraging in him an active orientation toward life instead of a
passive, self-pitying one. How the therapist does this will depend on training,
orientation, personality, flexibility, and clinical instincts. The one task in which
the therapist might find that professional training is deficient is in dealing with
the ''moral guilt" issue. A second task for which training and upbringing leave
the therapist ill-prepared is to listen, without displaying shock or
disparagement, to stories of mutilated bodies, the stench of death, and the
committing of atrocities.
Lifton (1973) suggested a strategy as old as the Church in tackling the "guilt"
problem: face up to your responsibility, and perform some type of symbolic
atonement as penance. Some may look on this approach as a neurotic one, a
form of "undoing"; but it has been effective for centuries in the Church, and
pragmatism looks like the approach of choice in this case. Some sort of active
effort on a veteran's part to contribute constructively to the community or to
other individuals may move him beyond crippling guilt.
The specialized programs for combat-related PTSD initially generated optimism
about therapeutic outcomes. In contrast, Kolb (1986) and Perconte et al.
(1989) have found considerable relapse and rehospitalization among veterans
once considered to be greatly improved. Their findings suggested a pattern of
chronicity that often develops among veterans with this disorder, and
emphasized the importance of ongoing support and intervention. Treatment of
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Page 388
hours to several weeks. Feelings of helplessness and depression that may last a
lengthy period of time mark the rape victim's transition to the second stage.
Ellis (1983) proposed another reactive model. Ellis noted that fear, depression,
and anxiety are present the first three months after a sexual assault.
Relationship problems and sexual dysfunction may last from three months to a
year or more after the assault. For instance, a sexual behavior that once was
pleasurable in a consenting relationship may
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The work of Amir (1971) demonstrated a propensity to blame the victim for the
assault. His pioneer research showed that 19 percent of rape victims in the
sample had police records, and "bad reputations" that contributed to their
sexual victimization. However, in a study of adolescent rapists, Vinogradov et
al. (1988) found that a large majority (88 percent) of the offenders said the
victim's words or acts had not provoked
Page 390
the rape. Most offenders (70 percent) reported that they did not consider the
victim to be sexually provocative, nor did they feel threatened by the victim. In
suggesting that the victim may have invited or precipitated a rape, Amir noted
that in 63 percent of rape cases in the study, both assailant and victim had
been drinking. Vinogradov et al. (1988) discounted the notion that rape victims
"ask for it," or send nonverbal messages that they are sexually available.
The victim's residence may be a consideration in being targeted. Many rapes
are not premeditated nor thought out, but are committed when the assailant is
engaged in other criminal activity, such as purse snatching, housebreaking, or
burglary. The National Crime Survey (U.S. Department of Justice, 1985) has
reported that one-third of completed rapes and one-fourth of attempted rapes
take place in the home. Less than half of the completed rapes, but over half of
the attempted rapes, take place in streets, parks, fields, playgrounds, parking
lots, or garages. Despite the attention given to date rape, a woman is twice as
likely to be raped by a stranger than by someone she knows (Divasto et al.,
1984). However, it is possible that rape is less likely to be reported when the
woman knows the assailant. The National Crime Survey statistics showed that
56 percent of victims reported the rape to the police when the assailant was a
stranger, whereas only 45 percent did so when the assailant was an
acquaintance or friend.
More often than not, rape is an intraracial event, with both victim and assailant
members of the same race. The National Crime Survey reports indicate that
when rapes are interracial, the offender is likely to be black and the victim
white. At the same time, the likelihood of being raped is disproportionately
greater for black women (Schneider et al., 1981). Rape is an extremely
emotional issue and it is possible that, for various social, political, and economic
reasons, less attention is paid to reporting and prosecuting assailants of black
women. Vinogradov et al. (1988) stated that rape victims were targeted mostly
because they were accessible and an assailant of superior strength could
overcome them.
The Stressor: Rape Trauma
Studies of peak periods for rape reveal a high incidence occur on weekends
and at night (Schneider et al., 1981). Two-thirds of all rapes and rape
attempts occur at night, particularly between 6:00 P.M. and 12:00 A.M. Analysis of
significant annual rhythms to rape occurrence shows that most take place in
the summer or in the early fall. Studies of rapists have indicated that they are
usually young men of urban background between the ages of sixteen and
twenty-five years of age; many have records of prior arrests. Sex offenders
often commit rape for the first time during adolescence, and there are high
numbers of repeaters (Vinogradov et al., 1988).
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Some experts allege that rape is often a planned event, but others point to
distinct subgroups of rapists. One subgroup consists of opportunistic offenders,
who commit rape without prior intent and only when the immediate situation
makes assault possible. The opportunistic rapist is usually involved in various
criminal activities, and the rape is almost an afterthought. Groth et al. (1977)
saw rape as an aggressive, not a sexual act. Groth characterized power rape as
premeditated and motivated by the rapist's need to control and dominate. His
conceptual model defined the anger rape as unpremeditated and
opportunistic, motivated by the rapist's chronic anger toward women. A third
type, the sadistic rape is probably the most traumatic of all, since its purpose is
to inflict pain and injury, and humiliation.
Although sexual intercourse may be of secondary importance, forced
intercourse represents to the rapist and to the victim a violation of her most
private self. Sadock (1985) wrote that one-third of rapists have erectile or
ejaculatory dysfunction during the assault, therefore giving credence to the
belief that the act of rape is aggressive rather than sexual. In instances of
sadistic rape, the degradation of the victim increases the sexual excitement of
the rapist. The girl or woman being raped believes herself to be in a lifethreatening situation, especially if the assailant has a knife or a gun. The rapist
may urinate or defecate on his victim, ejaculate into her face, or force objects
into body orifices. The DSM-III-R (American Psychiatric Association, 1987) is
cautious about linking rape to sexual sadism, but acknowledges the occasional
association between rape and sexual sadism.
Statutory rape refers to intercourse between a male over sixteen years of age
and a female under the age of consent. Age of consent ranges from fourteen
to twenty-one years old, depending on the locality. Thus, a girl of fifteen and a
young man of seventeen or eighteen may have a consensual sexual
relationship, but in some jurisdictions the man could be held for statutory rape.
Many forms of statutory rape are not assaultive and are truly sexual rather than
aggressive acts. Unless the age difference between the male and female is
great enough for the man to be considered a pedophile, statutory rape is not
considered deviant or perverted. In general, the parents rather than the
consenting girl file the charges of statutory rape.
The Social Context: External Supports
Many women who have been raped exhibit symptoms of post-traumatic stress,
Page 392
The victim deserves, but does not always receive, loving support from
significant persons in her life. She also deserves respect from persons
attending to her gynecological needs and from law enforcement personnel.
When a rape victim has the courage to report the assault, she may be the
object of innuendo and disbelief. This occurs less often than formerly, but
when it happens, the woman feels as if she has been raped a second time. She
is served best when physical and psychiatric care are offered in one location,
and when these services are coordinated with those of law enforcement
agents. Many metropolitan centers have a rape crisis team composed of
women on call twenty-four hours a day. These team members receive special
training and are sensitive to the physical and psychological trauma the rape
victims have suffered. Group therapy, led by a facilitator, with members who
have been sexually assaulted helps reduce the victims' sense of being unclean
and demeaned. Group referrals should follow crisis work.
The feminist movement has worked to promote changes that have aided rape
victims. Hiring policewomen has made reporting rape somewhat easier for the
victim. Rape crisis centers and hot lines are available to provide immediate
assistance and guidance. When a rape victim appears in court, she no longer
must prove that she actively struggled and suffered physical injury. Testimony
about the sexual history of the victim is not admissible in most states. These
changes are undoubtedly helpful, but rape remains a severe trauma with
lasting consequences for the victim.
More important than anything else is the behavior of husbands, parents, and
significant others to the rape victim. Moss et al. (1990) emphasized the
paramount importance of the husband's attitude. Sometimes the male partner
fails to support the victim because of his own sense of being victimized by the
assault. Another male partner who may initially have offered support, later has
problems interacting sexually with the victim of the assault. Other male
partners may engage in "blaming the victim," or assigning to the victim
responsibility for being raped. Needless to say, these reactive patterns
contribute to the victims' adjustment difficulties.
Brown and Prudo (1981) found that the marital relationship could either
protect or endanger the psychological well-being of any woman in the
aftermath of a stressful event such as rape. In particular, women who did not
feel free to share their emotional concerns with a spouse or boyfriend were
Page 393
or weeks after the assault, and tended to reduce his expectations of her. As
the victim's emotional problems continue beyond six to eight weeks, and she is
unable to function as usual in the marriage and in the home, the spouse
becomes impatient and angry. In such cases, marital counseling may be
necessary to help the husband understand the victim's need for more time to
adjust, and to monitor his demands on her. When a relationship becomes
problematic after the assault, it may be advisable to include the spouse in the
treatment and recovery of the victim. Intervention might include information
about the usual impact of rape so that the victim's behavior is interpreted as
normal rather than pathological.
Counseling the Rape Victim
The circumstances of the rape, the characteristics of the assailant, and the
events that happened during the rape will all influence the victim's reaction.
When and where was the victim approached? Where did the rape occur? Was
the assailant known to her? Was she threatened? Did he have a weapon? Did
she struggle? Guilt feelings about not resisting may add complications to the
client's recovery process. What type of sex was demanded? For many women,
the sexual aspect of the rape is highly distressing, especially if they have been
forced to commit acts that are repulsive to them.
In order to provide appropriate treatment, it is necessary to determine the
meaning of the sexual assault to the woman and her feelings about sex in
general. The rape may create difficulties in the victim's present relationships
and may stimulate doubt and fear about the possibility of future relationships.
The client's help-seeking behavior should also be explored. Where did the
woman go for help? What was the encounter with the police like for her? How
was she treated at the hospital? Is she considering pressing charges against
the rapist? Who is available to help her? Who can she confide in? Who is she
willing to tell about the experience? The social support systems of the victim
can make the difference between successful resolution and continued fear and
guilt.
The initial interview of the rape victim is of paramount importance in assessing
the client's amount of psychological distress and in determining a plan of care.
The purpose of the interview is to learn as much as possible about the incident
and about the victim's reaction to it. Attention should be given to the victim's
nonverbal responses. Her general appearance tells how she feels about herself,
which helps to assess the severity of the distress and the loss of coping skills.
She needs to be assisted in making decisions about whom and when she is
going to tell about the experience, and who will make up her support system.
By using available support
Page 394
systems, she can begin to regain the self-confidence needed to resume her
normal life style. The victim should be encouraged to resume her normal style
of activity as soon as possible, since delays only lead to difficulties later on.
The rape victim needs acceptance and empathy from practitioners, and from
significant persons in her life. Most detrimental of all to the rape victim is the
myth of the seductive female who misleads an unsuspecting male, or the
manipulative female who shouts "Rape!" in order to deny her culpability for a
sexual encounter. The feminist movement has done much to eradicate the
ordeal victims who wish to bring charges against an alleged rapist must face.
In most states the sexual experience of the rape victim is no longer a
compelling issue, and in New York a prostitute has the right to press charges if
sexual intercourse took place without her consent. Women no longer have to
prove that they physically resisted the rapist but only that they did not consent
voluntarily. Some states require women to attest to "earnest resistance."
Professional staff working in hospital emergency departments collaborate with
rape crisis teams and act as liaison agents when a rape victim is brought in for
treatment. Close work relationships between rape crisis workers and hospital
staff members prevent the destruction of important evidence during the post
rape examination and provide continuity of care for victims.
Rape is a traumatic event with great potential for precipitating crisis in victims
and significant others. Because the reactions of family members and significant
others to the assault are varied and unpredictable, it may not be advisable to
notify anyone until the victim has given permission in this regard. Many rape
victims need time to deal with their own feelings before being intruded on by
well-intentioned friends or relatives. The reaction of the sexual partner involved
with the victim prior to the rape is of crucial importance. If the partner is
concerned primarily with the emotional state of the victim and offers
unquestioning support, a state of severe disequilibrium in the victim may be
averted. If a husband, father, or fianc interprets the rape not as a crime
against the victim, but as a violation of his own rights, the needs of the victim
will not be met. Suggestions by family members, friends, or professionals that
hint that the behaviors of the victim encouraged the assault will intimidate the
victim and prolong self-recrimination.
Counseling following rape should be anxiety suppressive in nature, and
directed toward reestablishing the victim's sense of worth and value. Informing
the victim of her legal rights, helping her talk about the experience, and
enlisting her cooperation in apprehending and prosecuting the rapist are
measures that reduce feelings of helplessness. Even when the rapist is not
apprehended immediately, participating in the activities of law enforcement
agencies helps the victim to ruminate less about the
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Critical Guidelines
Women who are sexually active and women without prior sexual experience all feel
devalued by the rape experience. Many feel themselves changed in the eyes of
others and may have trouble resuming customary sexual activities. The reactions of
significant others and all persons providing treatment or counseling are extremely
important.
The attitude of Becky's husband after she was raped intensified her distress. Figure
15-1 delineates reactions of the rape victim and her significant other, which lead to
crisis. George's reluctance to report the rape to the police was understandable only
if he feared his wife might be the object of unsympathetic
Page 396
Figure 15-1
Paradigm of Crisis in Victim and Significant Other Following Rape.
Source: Adapted from Aguilera and Messick (1978).
treatment. It should be noted that reporting a rape to the authorities instigates
court proceedings only if the victim decides to bring charges. One advantage to
reporting a rape, even when physical trauma is not excessive, is that the event is
clearly labeled a criminal act and the woman is perceived as the victim
Page 397
of a crime, at least by the people who are most important to her. Failure to report a
rape consigns the incident to an ambiguous and perhaps unmentionable category of
events. Since discussing the experience with a supportive person helps most rape
victims, the rape should not be an unreported incident or a forbidden topic unless
the woman herself makes this decision.
Summary
The psychological impairment many Vietnam combat veterans suffered
contributed to our understanding of the phenomenon known as posttraumatic
stress disorder (PTSD). It is generally accepted in professional groups that any
catastrophic event beyond the normal range of human experience can
precipitate the PTSD syndrome. This realization has led to more comprehensive
programs for victims of war, torture, rape, terrorism, and harsh incarceration. A
three-factor analysis, consisting of the victim, the stressful event, and the
social context surrounding it, was used to discuss post-traumatic reactions of
combat veterans and rape victims.
The patriotic adolescent who went off to fight the brutal war in Vietnam often
returned home a disillusioned outcast. For many, the symptoms of delayed
PTSD began to appear months or even years after they thought that they had
put the worst behind them. Unable to explain their troubled thoughts and
feelings, and unaware that thousands of other veterans were having similar
adjustment problems, they began to believe that they were losing their minds.
The majority were not ''crazy" or psychotic. The symptoms they displayed are
likely to appear in any individual exposed to unusual trauma (in this case, war).
Given their age at the time, the unusual conditions of that war, and the social
milieu to which they returned in this country, it is no surprise that Vietnam
veterans are suffering stress-related symptoms, that their symptoms were
delayed, or that help for the problem was so slow in coming.
The self-help "rap" groups and the outreach programs were of monumental
importance in educating and assisting the veterans with the PTSD problem.
Therapy, especially within a group setting, can be very beneficial in helping
veterans control their symptoms and go on with their lives. Wives and family
members should also be included in the education and therapeutic processes.
Americans were not there with support or understanding when the warriors,
the survivors, came home. If Vietnam veterans are to successfully reenter the
mainstream of society, it is time for us to do what should have been done a
Page 398
names of the 57,939 dead or missing Americans was paid for through private
donations raised by the veterans themselves rather than by government
proclamation. It is not important that the Vietnam veterans decided to throw
themselves a "welcome home" party and to invite the rest of us to celebrate
with them, instead of vice versa. It is really inconsequential that Presidents
Reagan, Carter, Ford, and Nixon chose not to participate actively in the week's
festivities. What does matter is that, for perhaps the first time in their postVietnam lives and in front of all America, veterans stood together again with
their heads held high and often with tears in their eyes. Thanks to their
persistence and courage, they made us all remember their patriotism and
recognize their sacrifices. That one special week in Washington, D.C. does not
close the book on Vietnam or its warriors. The rituals of welcome-the memorial,
the speeches, and the parade-have finally been accomplished; but the reality
of homecoming-the acceptance, the understanding, the benefits, and the
educational and occupational opportunities-is yet to be fully realized.
The "homecoming" of rape victims often is disappointing. Some victims of rape
receive gentle, considerate treatment from family, friends, and care providers.
Unfortunately, this is not always the case. Improvements have been made in
the way the media, the legal system, and care providers treat rape victims, but
more are needed. Rape is an under-reported crime because women fear that
reporting rape will lead only to further victimization. This is an issue that
continues to attract attention from activists in the women's movement. Their
goal is to improve the social context that prevents rape victims from receiving
the help to which their ordeal entitles them.
References
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Amir, M. Patterns in Forcible Rape. Chicago: Chicago University Press, 1971.
Becker, J.V., L.J. Skinner, G.G. Abel, and J. Chicon. "Levels of Post Assault
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and Stratton, 1986.
Kormos, H.R. "The Nature of Combat Stress." In Stress Disorders among
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Lifton, R.J. Home from the War. New York: Simon & Schuster, 1973.
Lowenstein, L.F. "Who Is the Rapist?" Journal of Criminal Law 162(1977): 3742.
Marin, P. "Living in Moral Pain." Psychology Today November (1981): 68-80.
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Support on Rape Trauma." American Journal of Ortho-Psychiatry 60(1990):
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Newman, J. "Differential Diagnosis in Post Traumatic Stress Disorder:
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Perconte, S.T., M.L. Griger, and G. Bellucci. "Relapse and Rehospitalization of
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16
Multiple Trauma:
Victims, Families, and Caregivers
Perseverance is more prevailing than violence; and many things which cannot be
overcome when they are together, yield themselves up when taken little by little.
Plutarch
Page 402
specialists believe that the magnitude of this potential has not been adequately
recognized.
In this chapter, the impact of trauma will be explored as a potential cause of
situational crisis, experienced simultaneously by different persons or groups of
persons in response to the same event. Not only may the infliction of severe
injury or trauma constitute a true crisis for the victim, but that same event may
precipitate a crisis for the victim's family or significant others, and also may
threaten the equilibrium of emergency service personnel responsible for the
care of the severely injured or traumatized client. In this chapter, the potential
for trauma to precipitate a crisis in these three populations-the victim,
significant others, and care providers-will be discussed along with intervention
techniques that may be used. A major portion of the chapter deals with the
emergency service staff and their responses to severe trauma victims since this
is an aspect of crisis intervention that is often overlooked.
The event of multiple trauma as a cause of situational crisis has not been
extensively studied. It is, therefore, necessary to extrapolate findings from
related crisis research. Such extrapolation is a valid approach since all life
events, even the same life events, have unique meaning for the person
experiencing them. Crisis intervention research has established that, because
the precipitating event may vary and its meaning may be individualized for
each participant, the same event may precipitate a crisis in one person, but not
in another. There is, however, some universality of response to crisis across
populations, and this commonality is the basis of crisis work. In all trauma
there is the possibility of crisis not only for the victim, but also for other persons
or groups of persons, particularly the family or significant other, and the initial
caregivers, who are often members of the emergency department staff.
For many victims of trauma, especially polytrauma, the time immediately postinjury constitutes a pre-crisis state. The realization of the impact the trauma
will have on the victim's life has not yet been reached. Professional intervention
at this point can be of great importance. Pre-crisis and crisis episodes are
periods when the victim experiences decreased defensiveness, increased
openness, and diminished resistance to change (Puryear, 1980). If crisis
intervention theory and principles are used in the pre-crisis state, an impending
crisis may be avoided. Because of the proximity in time to the actual infliction
of the trauma, initial caregiving generally falls within the pre-crisis period. In
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that: (1) the emotions they are experiencing are natural in the circumstances;
(2) verbalization of fears and concerns is acceptable and will not be ignored;
and (3) assistance is available to help clients deal with their feelings, fears, and
concerns, either form the emergency department staff or from other sources to
which they can be referred.
Because the probability is so great that cases of trauma, regardless of severity,
will be followed by a crisis for the victim, the emergency department staff must
be:
Skilled in emotional assessment techniques.
Able to assess the impact the trauma has for each victim relevant to social
functioning and ability to cope.
Knowledgeable in crisis intervention theory and techniques.
Aware of hospital, professional, and community resources where the stressed
client can receive additional or continued support.
Supported administratively in their efforts to meet the emotional, as well as the
physical, needs of the trauma victim.
Trauma as Crisis
Is trauma always a crisis for the victim? The answer lies in the definition of
crisis as differentiated from emergency and the application of these terms to
specific cases. Whitlock (1978) defined emergency as an "unforeseen
combination of circumstances that calls for some kind of immediate action and
specific treatment of various kinds." Medically, the action or treatment is
necessary to save life or limb, or to prevent excessive morbidity. In general,
any person who suffers major insult to one or more body systems will require
immediate intervention to prevent mortality or excessive morbidity. Most
trauma, especially multiple trauma, can be safely defined as an emergency.
But is an emergency a crisis? Whitlock (1978) defined a crisis as a decisive
turning point beyond which something crucial will happen. In the medical
model, crisis is the point at which there is a change in the course of illness that
indicates whether the prognosis will be remission or death. For some
individuals, multiple trauma may remain an emergency rather than a crisis. For
other individuals, minor trauma may not be an emergency in the strict sense of
the term, but may precipitate a crisis for the victim, the family, and the
caregivers. Much depends on the meaning of the event to all persons involved,
their previous experiences in terms of stress, and the coping behaviors
available to them. These phenomena are illustrated in the clinical examples
that follow. An emergency may also be a crisis and a crisis may also be an
emergency, but a crisis may exist without being an emergency and an
emergency may exist without becoming a crisis.
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For every crisis victim, some family members or significant others are likely to
experience trauma to another individual as a personal crisis. For every multipletrauma victim treated, there is the additional possibility that the demands
made on the principal caregivers will precipitate a crisis for one or more of the
care providers. A crisis precipitated by sudden trauma may result from strong,
externally imposed forces that are unexpected, uncontrolled, and
overwhelming. Rape, sudden death of a spouse, and accidental physical
dismemberment are examples of trauma that often deteriorate into crises. The
sudden, unanticipated quality of the trauma renders usual coping behaviors
ineffective. Be it a precipitating event or a complication of an already-existing
crisis, the meaning the event has for the persons involved must be recognized
if planning and intervention are to be effective.
Classification of Crisis
Trauma may often be less a crisis in itself than an area in which other crises
are manifested. In most instances, trauma is a hazard or precipitator of crisis.
Physiologically, the specific injury can be a crisis when the injury represents a
turning point for life or death. Emotionally, trauma may be a precipitator of
crisis development or a complication of an existing crisis, either situational or
developmental. There are six basic classes of crisis which may be located on a
continuum of severity, with dispositional crises being the least severe (Brugess
& Baldwin, 1981).
1. Dispositional crises
2. Crises of anticipated life transactions
3. Crises resulting from sudden traumatic stress
4. Maturational/developmental crises
5. Crises resulting from psychopathology
6. Psychiatric emergencies
A trauma experience, regardless of the actual event of physical injury, may
worsen any of these six classifications. In this chapter, two clinical examples
are presented at length. In one example, the physical injuries of the victim
were not severe, yet a host of external factors along with the accident the
victim experienced led to crisis. In the second example, there was a fatality
that became a crisis for some, but not all survivors. The responses of caregivers
in both instances are discussed.
To intervene effectively in a crisis, it is important to know the sequence of its
appearance and eventual resolution. Baldwin (1977) identified the following
distinct phases in the life span of an emotional crisis. Adaptive and maladaptive
crisis resolution are compared.
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financial strain resulting from damage to her car and her absence from work, or
were deeper psychological forces operating here? Perhaps Karen unconsciously saw
injury as a valid excuse for relinquishing responsibilities that had become too
overwhelming for her.
Karen's crisis, although not life threatening like John's, was no less significant. A
crisis generally involves a loss or the threat of loss, or a radical change in the
person's relationships with self, significant others, or a situation. Loss can occur
through death, separation, change in status, or altered role relationships.
Perceptions of loss, threatened loss, or change result in a temporary inability to
cope, either because the stress is too great, because there is not adequate time or
energy to mobilize necessary coping skills, or there is inadequate experience in
coping. Karen never needed to cope with financial hardship prior to her husband's
death nor to deal with legal problems related to her adolescent son. She had been
suddenly catapulted from her familiar place as a dependent, protected woman to a
position of assuming total responsibility for the family. Her automobile accident was
an added financial and emotional strain that taxed her already-depleted coping
resources. By the time Karen arrived in the emergency department, she was
entering phase 3. By this stage, the tension has reached such a level internal and/or
external resources must be mobilized to improve the situation. If the crisis is not
resolved at or before this point, the client-victim will move into the manifestation of
overt pathology seen in phase 4.
When Karen's children arrived at the emergency department with a neighbor, it was
evident that while Tony appeared to have accepted his mother's trauma, Beth was
not handling the situation well. Beth was so impassive that the neighbor asked the
nurse to ''look at" Beth to see if she was all right. Apparently, Beth had responded
to the news of her mother's accident by complete silence and withdrawal. Careful
interviewing revealed that Beth's perception of this event was distorted in its
meaning for her. Beth feared that her mother's car had not been registered
properly, that the police would be involved, and a report made in the newspaper.
Her classmates at school already shunned her since police had arrested her brother
some months earlier. She had not been asked to the annual dance yet and believed
that she would not be invited because of her family's "criminal" record.
After her father's death, Karen had been forced to move the family to a less
expensive home in another part of town. Beth now attended a different school and
had not been able to see much of her best friend, who had lived next door to their
former home. Through the problem-solving approach, Beth's perceptions and social
supports should be assessed for their crisis potential. Although Beth and her mother
perceived the trauma incident differently, both experienced a crisis state. Tony did
not develop a crisis state in response to his mother's trauma. As the emergency
department staff cared for Karen, they assessed her response to the accident as
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led to the realization that Karen might not be able to function effectively for a time
after the accident.
Figure 16-1 contrasts the reactions of Karen's two children to their mother's
accident. Note that Tony, who had been guilty of a minor legal infraction, rallied to
his mother's support. In some respects, Tony identified with his mother because her
accident was a police matter, just as his infraction had been. Neither Tony nor his
sister had completely dealt with their feelings after their father's death. Tony,
however, had found a congenial peer group in the new neighborhood, but Beth did
not. Tony perceived his mother's accident as an opportunity to prove his worth to
her. Beth considered the accident further proof of her mother's inadequacy.
Three significant factors determine whether an individual remains in a state of
equilibrium or is propelled into crisis by trauma or any other stressful event. The
significant factors are: (1) realistic perception of the event, (2) adequate situational
support during the time of stress, and (3) an adequate repertoire of coping skills.
Assessment of the three factors can provide a
Figure 16-1
Paradigm of Crisis in Family Members After Minor Trauma.
Source: Adapted from Aguilera and Messick (1978).
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foundation for problem solving and for crisis resolving. It was Karen's lack of
situational support and her unpracticed coping skills that caused her to overreact to
her minor accident. These two deficiencies distorted her perception of the event,
which led to crisis.
Critical Guidelines
When an individual comes to an emergency department with minor injuries, good
physical care will likely be given. However, when the same individual becomes
extremely upset, the chances are that emotional distress will receive less solicitude.
This is unfortunate, since the emotional distress is often a cry for help from an
individual who no longer feels in control. In Karen's case, her children's problems
also needed attention. Her son's delinquent behavior and her daughter's
unhappiness were linked to the family's loss of the husband and father. This entire
family needed counseling, as their reactions to an apparently inconsequential
accident revealed.
Rather than discharging Karen after minimal care, the emergency department staff
should assess her response to her situation. Instead of criticizing Karen's behavior,
the staff should allow her to express feelings generated by the trauma and to
discuss individual perceptions of the traumatic event in addition to her own.
The generic level of crisis intervention uses supportive listening, but may include
environmental manipulation. While some cases of trauma crisis may parallel other
crisis reactions, especially those following a significant loss, the crisis of trauma has
not been studied enough to associate a particular pattern of response with it. One
or more types of intervention in the generic approach are appropriate to selected
trauma victims.
Providing general supportive measures that are appropriate in crisis situations.
Assisting the client to be more objective by encouraging a review of a present
situation. This approach may not be appropriate initially if the client needs to
ventilate feelings.
Encouraging the client to work out adaptive resolutions; identifying crisis as
something that could happen to anyone; exploring constructive actions available to
the client.
Manipulating environment selectively while assisting the client to make changes and
develop support network.
Providing anticipatory guidance, thus aiding in the prevention of future difficulties.
Of the two general types of intervention, modified anxiety-provoking approaches
would generally be appropriate only for the trauma victim whose reaction is
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the victim. In interventions with Karen, she should be dealt with as an adult with
adult responsibilities by introducing constructive actions she can take. Granted, it
would appear that it is the realization of her responsibilities that is overwhelming
Karen, but it is actually her distorted perception of those responsibilities that
impedes her progress. The key to helping Karen is not to do anything for her that
she could do for herself. Encourage her to make the necessary phone calls to
arrange for repairs to her car and to notify her boss, providing, of course, that she is
physically able to perform these activities. The caregivers should remind Karen of
her ability to manage, and help her to identify people who can offer her support.
Allowing a client to deny all need for help aids in avoiding reality. The well-meaning
emergency department staff member, by making the necessary phone calls or
acting as intermediary for Karen, may actually promote her regression into a pattern
of dependency. Having her take constructive, productive actions promotes selfconfidence and indicates that there are many aspects of this situation that she can
handle and over which she has control.
Environmental manipulation appears to be extremely appropriate for crisis work
with trauma victims. In addition, the caregiver should enact a supportive role
consisting of careful and active listening, which provides reassurance that the victim
is not alone. Environmental manipulation may involve removing excessive
responsibility from the client or removing the client from a demanding environment.
Neither of these is a full solution to the problem, but can be helpful temporarily. In
Karen's case, admission to the hospital for a short period of observation might
provide time in which to rally her psychological strengths. On the other hand,
hospitalizing her might promote regression and dependence, besides increasing her
financial burdens. While environmental manipulation is no guarantee of adaptive
crisis resolution, it can promote a sense of competence in some individuals.
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The number of family members who will be affected and the degree to which
each will be affected are rarely obvious to the emergency department staff.
Whereas a traumatic injury may not constitute a crisis for the victim, one or
more family members may interpret it as such. Fear of unknown consequences
is extremely difficult for family members to endure, and it is incumbent upon
staff members to explain necessary procedures and provide some accurate
information to the waiting family.
For significant others and family members as well as victims, trauma as a
situational crisis does not occur in isolation, but is superimposed on additional
developmental or functional conflicts that may already have taxed resources to
the utmost. When trauma to one member does result in crisis for the family,
the crisis usually pertains to actual or anticipated dismemberment (loss of one
of the members), often in combination with demoralization (loss of status).
According to Phipps (1980), three categories of family crises are:
1. Dismemberment. Loss of a member.
2. Accession. Addition of a member.
3. Demoralization. Loss of status.
Crisis intervention in emergency departments is a form of primary psychiatric
prevention, and to be optimally effective it must be instituted at the earliest
possible point in the interaction of the client with the caregiving system.
Among the positive aspects of crisis intervention in the emergency care setting,
Hankoff et al. (1974) identified the following:
With regard to logistics and economy of effort, the emergency department is
an ideal site for a program of crisis intervention. The population of emergency
care seekers contains a high percentage of clients at risk to develop crisis
states as a result of physical and psychological trauma.
Emergency service personnel have an orientation toward immediate assistance.
The emergency department is a common portal of entry into the caregiving
system, permitting the earliest recognition of clients at risk for crisis
development, and thus is a most desirable point for intervention/prevention.
Hankoff et al. (1974) also recognized several negative factors that hinder the
development of crisis intervention in the emergency department setting:
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Stage 1: Catharsis/Assessment
Affective Tasks:
1. The therapist encourages the client to acknowledge and to express feelings
that the crisis situation generated.
2. The therapist helps the client explore and to define the emotional meaning
of the precipitating event that produced the crisis.
3. The therapist motivates the client to search for solutions. During the search,
the therapist may provide direct help.
Cognitive Tasks:
1. The therapist helps the client to restore a realistic perspective of the crisis
situation and to define viable options or courses of action available.
2. The therapist helps the client to conceptualize the precipitant and the
psychodynamic meaning of the crisis situation that links the present to the past
(when this component of a crisis is present).
3. The therapist elicits limited, but relevant, background information from the
client to understand the crisis situation more fully.
Stage 2: Focusing/Contracting
Affective Tasks:
1. The therapist directs the client to an awareness of those feelings that impair
or prevent use of adaptive coping behaviors in response to the crisis situation.
2. The therapist strives to develop a therapeutic alliance with the client, with
emphasis on client responsibility for adaptive change and eventual crisis
resolution.
Cognitive Tasks:
1. From the client, the therapist obtains agreement on a concise statement of
the core conflict or problem that has produced the crisis.
2. Together, the therapist and the client, define a time and goal contract for
the crisis resolution process.
3. The therapist and the client agree on a tentative therapeutic strategy or
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3. The therapist helps the client to respond directly and appropriately to the
crisis situation in terms of both issues and feelings (i.e., direct communication
with significant others involved is encouraged).
Cognitive Tasks:
1. The therapist teaches the client to develop new or more adaptive coping
responses and problem-solving skills.
2. The therapist helps to define client progress in working toward stated goals
for crisis resolution.
3. The therapist prevents diffusion of the therapeutic process away from the
focal problem and the goals defined for crisis resolution.
Stage 4: Termination/Integration
Affective Tasks:
1. The therapist elicits and responds to termination issues, but does not
prolong the therapeutic process because of them.
2. The therapist reinforces changes in coping behaviors and affective
functioning, and relates these changes to adaptive resolution of the
problematic situation.
Coping Tasks:
1. With the client, the therapist evaluates goal attainment or nonattainment
during the crisis intervention process.
2. The therapist uses anticipatory guidance to help integrate adaptive change
and to help prepare the client to meet future similar situations more
adequately.
3. The therapist provides the client with information about additional services
or community resources, or makes a direct referral for continuing therapy, as
appropriate.
Clinical Example: Crisis in a Significant other after Major Trauma
John Whitman was taken to the emergency room via ambulance following an
accident in which his motorcycle struck an oncoming car. John had multiple
fractures, deep lacerations, and contusions. He was thrashing about, screaming that
he could not breathe. The emergency staff rapidly intubated him and mechanically
ventilated him. Five minutes after intubation he had a cardiac arrest and could not
be resuscitated. John's fiance who was riding the motorcycle with him, was dead
on arrival at the emergency room.
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John Whitman's medical condition was a true emergency. He required immediate
intervention to allow him to continue to live. In addition, John experienced a crisis
that unfortunately ended in his death. John's crisis was a tension pneumothorax that
the emergency room personnel did not correctly identify. The mechanical ventilation
that the staff administered is contra-indicated in untreated tension pneumothorax.
In John's case, the emergency situation deteriorated into a crisis partly because of
the emergency measures that were taken.
John's mother and sister were notified that there had been an accident. They
arrived at the same time as the parents of John's fiance. Both families were taken
to a quiet room and told that the two young people had died. The girl's father and
John's sister, Sharon, viewed the bodies; the two mothers did not wish to do so. The
fiance's mother was tearful and distraught, but she seemed to turn to her husband.
Sharon tried to comfort her mother, but was less successful. John's mother was
tearless and seemed to be in a state of shock. "I can't believe it," she kept
repeating. "What is going to happen next in this family?"
Although Sharon, too, was devastated by her brother's death, she rallied to help her
mother in every possible way. In the past, she had often been her mother's
mainstay, and she quickly assumed her familiar role. To herself she promised that
her two boys would never have motorcycles, but she did not share this with her
mother or the dead girl's parents.
John's mother was a widow and Sharon realized that her mother's pain was greater
than her own. Happily married and the mother of two boys, Sharon drew comfort
from knowing that her own two boys were safe at home. The victims were more
central to the life of Alice, the mother than to the daughter. Neither woman
engaged in blaming nor in perceptual distortion, but Sharon's mourning was
facilitated by her husband and other supportive persons whom she used
advantageously in accomplishing necessary grief work. Although Sharon
accomplished adaptive grieving after her brother's death, her mother did not. John
had lived at home with his mother; he and his fiance planned to live with the older
woman after their marriage. About seven years before John's accident, his father
had succumbed to cancer after a long illness during which John's mother, Alice, had
provided most of the care. Sharon had been somewhat shielded from the burden of
her father's illness because she was already married and living in her own home.
Only two years older than John, Sharon was fond of her brother and devoted to her
mother. However, she did not feel alone and abandoned, as her mother did. Staff
members observed that Sharon was more concerned for her mother than herself.
When they found that John's mother was alone, they suggested that Sharon either
go home with her mother or bring her mother to her home. The parents of the dead
girl were overwhelmed by the accident, but they had each other for comfort. Figure
16-2 compares the crisis reaction of Alice, John's mother, with the adaptive grieving
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Figure 16-2
Paradigm of Crisis in Family Members After Major Trauma.
Source: Adapted from Aguilera and Messick (1978).
Critical Guidelines
The death of two young people was difficult for emergency staff members to deal
with. The death of John Whitman was especially harrowing. Not only had he been
alive when he arrived at the emergency department, but he had been
misdiagnosed. In all probability he would have succumbed to his injuries, but the
staff wondered whether he might have survived if other measures had been
instituted. The burden placed upon caregivers when rescue efforts fail is very heavy,
even when they can assure
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themselves that everything possible was done on the patient's behalf.
Emergency staff members work under pressure. Saving lives and responding to
medical needs is the first priority. After the death of John Whitman and his fiance,
staff members turned their attention to the families. It was apparent that the
mothers, in particular, might need help in dealing with their unexpected losses.
Without predicting difficulties, an emergency staff member suggested visits to
respective family doctors within the next few days for both mothers; this time would
inevitably be difficult for everyone. The staff emphasized the desirability of grieving
and expressing one's feelings, and gave the phone number of the hospital mental
health clinic, ''Just in case anyone needs to talk in the next few weeks." Emergency
room staff assured the family of their continued availability to answer questions the
families might have.
In this busy emergency department, there was no formal mechanism for extending
help to the families of trauma victims. If, later, the family in its grief communicated
with the emergency staff, they would be received in a friendly fashion, and perhaps
referred to a mental health facility. The lack of any program to assist families of
trauma victims gave a message to caregivers that their responsibility began and
ended with medical care for the victims. Unlike some emergency departments
where there is a mental health consultant available, emergency staff had no one to
consult when family members needed grief counseling or when personnel needed
support for their feelings of discouragement.
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General:
The Courage to Grieve:
Creative Living, Recovery,
and Growth Through Grief,
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anniversary of the death, unless the family has already solicited help. Coolican
(1989, p. 57) stated that "We've found that a personal call from a volunteer at
this point is critical because until that time, families tend to be surrounded by
relatives and friends. But then, a few weeks after the loss, they're left to grieve
alone."
When it is appropriate, a referral may be made to a support group, or to a
private therapist if the family desires. Many families do not understand the grief
process and are alarmed by the emotional maelstrom they are experiencing.
Many people need reassurance that what they are experiencing is normal,
given their circumstances. The After Care personnel stay in touch with families
up to two years after the death; termination is by mutual consent.
Crisis for Trauma Caregivers
Every emergency service care provider is at risk to experience a crisis state in
relation to caring for the multiple-trauma victim. Caplan established that an
emotionally hazardous situation can occur when a change in the individual's
environment alters expectations of self in ways perceived to be negative.
Trauma and polytrauma place unrealistic demands on emergency care
providers that they feel compelled to meet. If the caregiver is unable to meet
these unrealistic demands, and life-sustaining efforts prove unsuccessful, the
caregiver may interpret death as a result of personal inadequacies. The result
may be severe damage to the caregiver's self-esteem and feelings of
competence.
A second aspect of trauma that may add to the caregiver's feelings of
inadequacy is the interaction with the family or significant others of the
critically or fatally injured victim. The caregiver is faced with the dilemma of
trying to prepare the family to deal with probable death, while at the same
time working diligently to save the victim. Standard ways of helping family
members to cope with impending death, such as involving them in the care of
the dying person or just having them present, are not feasible when dealing
with the critically injured. Proved methods of assisting the patient to face
death, such as allaying fears, allowing control of the environment, and
promoting security through familiar objects, are not possible when dealing with
a severely traumatized victim. Dealing with seemingly insurmountable obstacles
in two crucial areas may significantly increase the caregiver's own susceptibility
to crisis reactions.
Puryear (1980) identified five characteristics of a crisis state that can be readily
associated with responses to polytrauma seen in certain emergency service
personnel.
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but also did nothing to restore her damaged self-esteem. Maladaptive resolution of
crisis for a health worker in this situation is shown in Figure 16-3.
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Figure 16-3
Trauma as Crisis for Caregivers.
Source: Adapted from Aguilera and Messick (1978).
Critical Guidelines
Jan's understandable, but maladaptive, response to the crisis of trauma is common
among caregivers in acute settings. The most common responses to crisis are
anger, passivity, desperation, or denial, all of which are reactions that reflect
feelings of anxiety and self-doubt (Puryear, 1980). Perceiving one's self as not being
capable of helping others is damaging to one's self-image as a competent, capable,
helping professional. To protect one's self-image, the caregiver may resort to
blaming others openly for the failure of joint efforts. In addition, anger may be felt
at the victim for being careless enough to be injured. Unfortunately, this global
blaming leads to feelings of guilt that further damage one's self-image as a
compassionate, understanding caregiver. The post-crisis adaptation of this nurse left
much to be desired.
The caregivers know that when a trauma victim arrives in an emergency
department, that victim's needs will disrupt usual tasks and responsibilities.
Sometimes the trauma caregiver is willing and able to request additional personnel
to assist. In
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most cases, this is an acceptable response. It alleviates the fears of personnel that
they will be overwhelmed by demands of the situation. If caregivers are
unexperienced in handling the type of injury that is presented, or if a disaster has
sent large numbers of victims simultaneously to an emergency department, feelings
of inadequacy arise and further impede staff efforts to cope. Helping efforts that do
not produce desirable results may engender a crisis state in some caregivers. Crisis
in caregivers may take the form of distancing themselves from colleagues or
blaming other staff members for the trauma victim's failure to respond.
Caregivers cannot altogether avoid emotional reactions. Feelings of satisfaction and
joy certainly prevail when the caregivers' hard work saves a life or prevents
disability. Cognitive and objective evaluations of treatment administered to trauma
victims are preferable and go far to avoid staff burnout. Such evaluations should be
team focused, should avoid the scapegoating of any health team member, and
should have the goal of improving care for other trauma victims.
Superimposed on or contributing to crisis response to trauma by emergency room
personnel is the grieving process that the staff experiences each time a patient dies.
Most individuals, survivors and caregivers alike, react to grief by progressing through
stages of anger, depression, rationalization, and acceptance, but at different rates.
Unlike the victim's family, there is a high degree of probability that the caregiver will
be exposed to another trauma-related death before the preceding crisis has been
resolved and the grieving process has been completed. With the period for crisis
resolution estimated as six weeks and the intervals between trauma victims often
much less than that, there is little opportunity for resolving the crisis before
additional stress is introduced.
With emergency department staff, it may seem to be a single-trauma victim that
triggers a crisis situation. In actuality, it may be that the failures and frustrations of
managing trauma victims in the past are culminated in a single incident. Not all
caregivers will be precipitated into a crisis by the advent of a trauma victim, nor will
every staff member who has undergone a trauma-related crisis suffer subsequent
crises related to trauma care. Two key concepts are especially appropriate to
trauma-related crises in the emergency care staff. The first concept is that of
prevention of crises in this high-risk population. The emergency department staff
must be supported and assisted in various ways that increase and maintain selfesteem and feelings of control. Providing a nurturing, supportive environment for
emergency caregivers is the primary level of crisis prevention. It is important to
assist personnel in coping with the trauma situation. A comprehensive assessment
and recording tool has been devised that can be used in the initial care of multipletrauma victims. The tool promotes feelings of competence and control by not only
serving to record assessment findings, but also by acting as a guide of assessments
to be made. Accurate, complete assessment of the multiply injured client is
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The second concept relevant to the emergency department staff is that success in
coping with one crisis will increase the ability to cope with future crises. Each
trauma case must serve to increase the trauma nurse's intervention skills. If the
trauma nurse is not assisted to cope with demands and personal feelings, eventual
response to the advent of each trauma victim will be crisis with maladaptive
resolution.
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Figure 16-4
Emergency Record of Multiple Trauma
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Figure 16-4
(continued)
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Figure 16-4
(continued)
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Figure 16-4
(continued)
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Figure 16-4
(continued)
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___. "A Paradigm for the Classification of Emotional Crises: Implications for
Crisis Intervention." American Journal of Orthopsychiatry 48(1978): 538-551.
Boulanger, G. "A State of Anarchy and a Call to Arms: The Research and
Treatment of Post Traumatic Stress Disorder." Journal of Contemporary
Psychology 20(1990): 5-15.
Brown, D., and E. Witztom. "Recent Trauma in Psychiatric Outpatients."
American Journal of Orthopsychiatry 62(1992): 545-551.
Burgess, A.W., and B.A. Baldwin. Crisis Intervention: Theory and Practice.
Englewood Cliffs, New Jersey: Prentice-Hall, 1981.
Coolican, M. "Helping Survivors Survive." Nursing 89 19(1989): 52-57.
Hankoff, L.D., M.T. Mischorr, K.E. Tomleson, and S.A. Joyce. "A Program of
Crisis Intervention in the Emergency Medical Setting." American Journal of
Psychiatry 131(1974): 47-50.
Kolb, L.C. "Chronic Posttraumatic Stress Disorder: Implications of Recent
Epidemiological and Neuropsychological Studies." Psychological Medicine
19(1989): 821-824.
Phipps, L.B. "Theoretical Frameworks Applicable to Family Care." In Familyfocused Care, edited by J.R. Miller and E.H. Janosik. New York: McGraw-Hill,
1980.
Puryear, D.A. Helping People in Crisis. San Francisco: Jossey Bass, 1980.
Whitlock, G.E. Understanding and Coping with Real Life Crises. Monterey,
California: Brooks/Cole, 1978.
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PART SIX
CRISIS PROGRAM PLANNING
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17
Crisis Programs:
Collaboration and Diversification
Things in life will not always run smoothly. Sometimes we will be rising toward the
heights-then all will seem to reverse itself and start downward. The great fact to
remember is that the trend of civilization is forever upward ...
Endicott Peabody
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about some aspect of the workshop, the participants betrayed, with quivers in
their voices, the lingering memories of the disaster. Although these workers
had performed heroically, they were haunted by a sense of their helplessness.
Terrible recollections of pieces of human bodies found in the disaster site
continued to disturb them. For many workers, the experience was particularly
painful because they sometimes found it necessary to cut through the bodies
of the dead in order to reach survivors. Even though most of them were
experienced rescue workers, they were accustomed to handling both the living
and the dead respectfully, keeping bodies as intact as possible. Dismembering
the dead, even to help survivors, was an act of violation for many of the
workers.
Inability to avert tragedy was a poignant memory for some workers. One
participant reported staying with an eleven-year-old boy while other workers
labored to remove huge pieces of rock and debris that covered the child. After
five hours of effort, the child was finally extricated from the rubble, only to die
twenty minutes later in the arms of the worker who had been with him
throughout the ordeal of the rescue effort.
Mental Health Workers
The usual skills developed in the education and preparation of mental health
professionals are often diametrically opposed to the skills necessary to deal
with the crisis experience of a client with whom the mental health professional
did not previously have an ongoing relationship. If the mental health
professional abides by the usual forms of therapeutic intervention, the client in
crisis may feel rejected and unaided. The overall approach to crisis intervention
requires more activity and more directiveness on the part of the helper than is
operant in other therapeutic modalities. The crisis worker needs to be more
flexible in reference to the use of space and time than is common in other
forms of therapy. In response to a client in crisis, the counselor may use
touching, even to the extent of holding a distraught client who is in acute
crisis. Admittedly, for some mental health professionals, the use of touch will
be difficult and even problematic. If, however, the professional is comfortable
with the use of touch, it can be a very effective technique.
The crisis worker also needs to be flexible regarding time factors. A client who
is experiencing crisis will rarely fit neatly into a fifty-minute hour or a once-aweek schedule. It is not at all uncommon for a first crisis session to last from
two to four hours, and for the next session to be scheduled later that day or for
the next day. A person in crisis may need to be seen daily for several days,
with the frequency of contact diminishing over the space of a few weeks. The
main point is that persons in crisis need to know they can reach help at any
time, even in the small hours of
Page 439
the morning if the need is urgent. This kind of flexibility and lack of structure
may prove quite difficult for the qualified mental health professional who does
not have an adequate grasp of crisis theory.
Another aspect of crisis intervention that is foreign to traditional mental health
counseling is the acceptance of the client's dependency, which often
accompanies initial crisis work. The crisis worker should be willing to accept
temporary dependency without interpreting such phenomena as transference
and countertransference. This dependency can be made acceptable by
establishing a clear understanding that crisis work is a time-limited experience
and that the client will return to a state of equilibrium in the foreseeable
future.
Emergency Room and Ambulance Workers
An important consideration in collaborative crisis work is identifying special
groups that are competent and skilled in handling certain types of crisis. Classic
examples of this kind of group are ambulance crews and emergency room
staffs. These are professionals and paraprofessionals who are exceedingly well
trained in the medical aspects of acute crisis care. Because of the extreme
importance of the medical emergency, these groups may not be altogether
aware of the multifaceted nature of crises and therefore restrict their
assistance to interventions that are entirely medical. Comprehensive training of
medical professionals and para-professionals requires sensitizing them to the
emotional components of a medical crisis, for medical personnel may overlook
emotional threats as they concentrate on the life-threatening aspects of the
experience. Similarly, mental health professionals and crisis center workers will
benefit from specialized training in understanding the rudiments of acute
medical care; the points of view of medical treatment teams; and the policies
and protocols of ambulance crews, hospital emergency personnel, and police
officers or firefighters.
Understanding the responsibilities of other care providers is necessary if the
crisis worker is to help clients anticipate and accept essential medical
procedures. Comprehending the rationale for certain treatments reduces anger
and resentment at what may seem to be callous or indifferent attitudes on the
part of medical specialists or rescue teams. Recognizing that crisis is a
multidimensional situation enables the crisis worker to realize the value of
interdisciplinary cooperation. Any programs designed to prepare crisis workers
Page 440
Peer Counseling
The use of the peer counseling service began during the 1960s and 1970s,
when the rise of counterculture influences challenged established values and
life styles. The ability of mental health professionals to deal with the
Page 441
Training Programs
Early training sessions for volunteers combine didactic instruction with
experiential learning. There are three major activities involved in experiential
learning: role playing, role portrayal, and interpersonal recall.
Page 442
The issues of support and guidance for crisis center volunteers are crucial. Of
special importance is quality control, or maintaining high standards for services
that crisis centers and crisis hot lines offer. The volunteers who answer crisis
hot lines must deal with a wide range of problems,
Page 443
The most helpful way to monitor the performance of workers and to improve
their skills is to record and listen to as many tape-recorded phone calls as
possible. Routine monitoring of the calls permits analysis of difficult calls,
provides supervision, and becomes a teaching method when selected calls are
used for didactic instruction of one or more workers. Random monitoring of
calls is less advisable than routine monitoring, but helps provide some degree
of quality control.
Page 444
Many of the issues around support for the workers and quality control for the
work can be discussed at regular meetings that the volunteer and professional
staff attend. Such meetings should be held at least monthly and more often if
possible. Here the volunteers can be given opportunities to talk about some of
their more difficult calls, to share ideas as to how calls might be handled, and
to review selected segments of actual calls. Serious attention should be paid to
the psychological satisfaction of volunteers working on a crisis hot line service,
and planned activities need to be built into the training program to build
morale and maintain high motivation. Certificates of service and other tokens of
recognition are usually very meaningful to volunteer workers. Experienced and
dedicated volunteers are the life supply of many crisis centers, and problems
related to burnout or volunteer discontent must be acknowledged. Many of the
larger, well-staffed crisis centers have a policy of assigning two or more
volunteers to the same time schedule. This practice is very helpful in that
volunteers can talk with one another and engage in mutual sharing after a
difficult phone conversation. Even when two or more volunteers have been
assigned to a shift, the need for prompt access to a supervisor or experienced
professional cannot be avoided.
Volunteerism in Crisis Work
Crisis intervention can often assist individuals to resume task-oriented
behaviors and discard defensive reactions. It is this primary objective that
benefits from the voluntary efforts of natural helpers in social settings, such as
relatives, friends, teachers, and clergy. A distinction should be made, however,
between the informal efforts of random individuals and the formal efforts of
structured crisis teams, staffed by volunteers.
When the interventions of natural helpers fail, persons in crisis often avail
themselves of assistance that diversified community programs offered, which
rely on the work of volunteers as well as paid workers. Because some
community workers, professional and otherwise, perceive crisis intervention as
a catchall term applied to a host of therapeutic tactics, their understanding of
specific principles may be vague. Collaboration is the rule rather than the
exception in crisis counseling, but adequate preparation and supervision should
be ongoing, especially for volunteers, regardless of their skills in other areas. In
all crisis work, formal or informal, commitment to quality control and outcome
evaluation is essential. Providing consultation and education to voluntary
workers reinforces the idea that the work they perform is important.
Page 445
volunteers are not taught rote answers or techniques. The aim is to prepare
volunteers, emotionally and cog-
Page 446
nitively, for crisis work and for the calls they are likely to receive. Volunteers are
asked to make a commitment to work one five-hour shift a week and one overnight
shift a month, plus attending a monthly staff meeting. Three volunteers are
assigned to each daytime shift, and two are assigned at night. Telephones are
answered twenty-four hours a day, and the facility is open from 9:00 A.M. until 10:00
P.M. for people who wish to come in and talk. Volunteers are carefully screened for
their personal qualities and aptitudes, without regard to sex, age, creed, or social
status. Although not prepared in the professional sense, these volunteers are well
trained and fully supervised with the help of professional consultants.
The Boston chapter is considered a charitable trust, so contributions to it are tax
deductible. Thus far, funding has been provided by foundation grants and donations
from businesses, insurance companies, and private citizens. Some financial support
is obtained through public subsidies from the Department of Mental Health. Three
directors, each with a designated area of responsibility, share administrative
authority. A board of trustees meets as a body or in committee to deal with
finances, public relations, and related issues. Additionally, staff and volunteers offer
presentations and training programs to hospitals and clinics, nursing and social work
schools, police groups, and other hot line and crisis centers (Samaritans, 1976).
Summary
In crisis work there are few territorial barriers between experienced helpers, for
the contributions of professionals, paraprofessionals, and nonprofessionals are
all significant. There is a tendency, however, for some mental health
professionals to concentrate on the emotional effects of crisis while overlooking
urgent needs for medical intervention. At the same time, medical emergency
workers may unintentionally cause psychological damage because of their
preoccupation with physical trauma. It is essential then that the special skills of
each group augment the skills of the others in order to prevent physical and
psychological damage following the precipitation of crisis.
The importance of preparing individuals for crisis work cannot be stressed too
much, and the experience in preparing and supervising volunteer crisis workers
suggests several appropriate training tactics, such as marathon sessions and
role portrayal. The impact of tragic disasters on crisis workers engaged in
rescue operations is powerful and long lasting. Emotional support and
opportunity for catharsis may be necessary intermittently for rescuers and
survivors, even after considerable time has elapsed since the event.
Many crisis centers and crisis hot lines are staffed almost entirely by volunteer
Page 447
training programs used to prepare them. Training programs for volunteer crisis
workers must warn them of frustrations encountered in dealing with situations
for which there are no definitive answers, and also prepare them for the guilt
they may experience when an intervention is unsuccessful. In addition to
careful selection and adequate training of volunteer workers, crisis programs
must strive for quality control through monitoring and supervising. Because of
the rigors of crisis work, support for personnel is just as necessary as quality
control. A clinical example that exemplifies admirable merging of selection,
training, quality control, and community collaboration is found in the program
of the Samaritans, a worldwide organization with a crisis center operating
successfully in Boston since 1974.
References
Cozza, K.L., and R.E. Hales. "Psychiatry in the Army: A Brief Historical
Perspective and Current Developments." Hospital and Community Psychiatry
42(1991): 413-418.
Hales, R.E. "Community Psychiatry: Alive and Thriving in the Military." Hospital
and Community Psychiatry 38(1987): 1259.
Hoff, L.A., and A. Resing. "Was this Suicide Preventable?" American Journal of
Nursing 82(1982): 1106-1111.
Kagan, N., P.A. Schauble, A. Ressikoff, S.J. Danish, and D.R. Krothwohl.
"Interpersonal Process Recall." Journal of Nervous and Mental Disorders
148(1969): 365-374.
Samaritans. Mimeographed Report, Boston, Mass. Samaritans, 1976.
The New York Times. "Hyatt Regency Disaster One Year Later." C1 July 5,
1982, C1.
Ursano, R.J., H.C. Holloway, and D.R. Jones. "Psychiatric Care in the Military
Community: Family and Military Stressors." Hospital and Community Psychiatry
40(1989): 1284-1289.
Page 448
INDEX
A
Abuse (see Child abuse; Spouse abuse)
Abusers' traits, 268-270
Abusive parents, interventions with, 271
Acquired immune deficiency syndrome (see AIDS)
Active theory and aging, 204
Acute grief, 27
Acute illness, definition of, 243
Acute post-traumatic stress disorder, 374
Adaptational theory, 44-45
Adaptive solution, 21
Addict in crisis, 20-21
Adolescents in crisis, 109-133
attachment, 109-111
cognitive development, 111-113
counseling, 132-133
identity, 126-132
moral judgment, 113-116
sexuality, 117-125
somatic changes, 116-117
temperament, 111
Adoptive parents, 191-193
Adults in crisis (see Aged adults in crisis; Middle-aged adults in crisis; Young
adults in crisis)
Aged adults in crisis, 199-234
adapting to aging, 202-203
care facilities, 216-222
caregivers' dilemma, 212-216
loss, 223-226
relocation, 210-212
retirement, 203-210
suicide, 226-230
Aggression:
definition of, 265
and rape, 391
Aging:
adapting to, 202-203
vs. aged, 199
personality patterns, 201
AIDS, 343-368
counseling, 355-356, 358-359, 360-361, 363-365
families of individuals, 356-359
health care professional, 361-365
HIV, 347-351
management styles, 353-355
parameters, 345-347
services for individuals, 351-352
survivors, 359-361
Alcohol abuse:
and child sexual abuse, 278
and violence, 294-295, 301
Alternative outcomes in family crisis, 74
Ambulance workers, 439
Amniocentesis, 143
Anaclitic depression, 89
Analyses of crisis, 41-60
adaptational theory, 44-45
anxiety, role of, 46-50
crisis work, types of, 50-53, 58-59
interpersonal theory, 45-46
psychoanalytic theory, 42-43
systems theory, 41-42
Anger/blame and divorce, 169
Anorexia nervosa, 129-130, 131
Anticipatory guidance, 32-33
Antisocial behavior of adolescents, 110-111
Anxiety, 45, 46-50
Anxiety-provoking crisis intervention, 51-52
Anxiety-provoking treatment, 50-51, 54
Anxiety-suppressive crisis work, 52-53
Anxiety-suppressive treatment, 52, 54
Application principles, 70-77
assessment, 70-72
critical guidelines, 75
evaluation, 75-76
Page 449
implementation, 73-74
locus of causation, 76-77
planning, 72-73, 74
Assessment:
of crisis situation, 70-72
and crisis work, 48
Attachment:
and adolescents, 109-111
and children, 88-102
and elderly couples, 223-224
B
Battered children syndrome, 266
Battered women and sexual abuse, 300-301 (see also Spouse abuse)
Behavior modification, 18, 44
Behavior patterns, young adults, 140-141
Bereaved families, bibiography for, 418
Binuclear family system, 177
Body image and adolescence, 129-131
Bonding, 88-90
Brainwashing resulting from beatings, 298
Bulimia, 130, 131-132
Burnout:
and disasters, 325-326
occupational, 144
C
Caplan, G., 6
Care facilities for elderly, 216-222
behavior of elderly, 217-218
Career choices and young adults, 150-153
Caregivers for elderly, 213-214
Castration anxiety, 46
Categories of crisis, 63-84
application principles, 70-77
compound, 67-68
developmental, 64-66
situational, 66
Child abuse, 265-286
abusers' traits, 268-270
counseling family, 270-273
definition of, 266
incestuous families, counseling, 282-286
sexual abuse, 277-282
Childbearing (see Sexual/reproductive decisions of young adults; Pregnancy
and young adults)
Childless couples, 154-155
Children in crisis, 87-107
attachment, 88-102
cognitive development, 87, 94-97
counseling, 103-106
Page 450
D
Date rape, 390
Death, childhood concepts of, 97-98
Decision crises and young adults, 141-153
career choices, 150-153
occupational stress, 143-145
risk taking, 146-147
sexual-reproductive priorities, 141-143
Defense mechanisms, 7-8, 45
Defensiveness, 10-11
Delayed grief reaction, 225
Delayed post-traumatic stress disorder, 375, 376
Denial:
and AIDS, 352
definition of, 7
and illusions, 139-140
and rape, 388
Dependency patterns, 141
Depression and the elderly, 225
Deprivation index, 332
Detachment:
from loved one, 25, 26
patterns, 141
Developmental crises, 64-66
Directive advice as intervention, 161
Disaster, definition of, 319
Disasters, 315-341
burnout, 325-326
classification of, 318-319
counseling survivors, 326-328
economic, 330-336
epidemiology, 316-317
reactions to, 323-325
role reorganization, 322-333
unemployment, 330-336
unseen, 328-330
Disengagement theory and aging, 204
Disorganized families (see Marginal families)
Displacement, definition of, 7
Distorted grief reaction, 26, 225
Page 451
Divorce, 165-181
effects on children, 167-168
joint custody, 176-179
loyalty issues, 168-170
mediation, definition of, 170-171
mediation and process, 170-174
mothers without custody, 179-181
single parent, 179, 181-183
Domination patterns, 141
Dormancy period, 21
Drug abuse and adolescents, 118
Dual-career marriage, 156-159
Dysfunctional person, definition of, 44
E
Eating disorders, 129-132
Economic disasters, 330-336
Elderly (see Aged adults in crisis)
Emergency:
definition of, 403
and crisis, 20-22, 23-24
Emergency record of multiple trauma, 424-428
Emergency room workers, 439
Emotional catharsis, 9
Empowering relationships, 261
F
Family:
and AIDS, 356-359
dimensions of, 248-256
tasks and divorce, 174-176
violence (see Child abuse; Spouse abuse)
Feminist formulation and wife beating, 296-298
Fight-flight behaviors, 29, 49-50
Financing long-term nursing home costs, 219
Flashbacks and post-traumatic stress disorder, 375
Foreclosure and identity, 126-127, 127-128
Formal operational stage of development, 96-97
Free association, 43
Frustration, 49
G
General adaptation syndrome (GAS), 19
Grief, 22, 25-29
vs. depression, 22, 25
and divorce, 174-176
H
Hazardous events:
classification and examples, 4
definition of, 4 (see also Disasters)
Health care professional and AIDS, 361-365
Helpless behavior, 49-50
Hierarchy of needs (Maslow), 33
HIV, 347-351
Homicidal thoughts, 71
Hopeless behavior, 49-50
Hot line workers, 440
Human immunodeficiency virus (see AIDS; HIV)
Husbands of rape survivors, 392-393
I
Identification, definition of, 8
Identity and adolescents, 126-132
Illness and disability, 239-254
marginality in families, 240-245, 260-262
sick role, 245-256
vulnerable populations, 256-260
Illusions and denial, 139-140
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J
Job-related stress (see Occupational stress)
Joint custody, 176-179
K
Kohlberg, L., 113-116
L
Learned helplessness, 298
Life cycle (Erikson), 138
Life cycle model of marriage, divorce, remarriage, 166
Life stages, 64-65
Life tasks, 99
Lindemann, E., 6, 25-26
Loss:
and divorce, 169
and the elderly, 223-226
of loved one, 25, 27
Loyalty issues and divorce, 168-170
M
Magnification, definition of, 10
Maladaptive behaviors, 44
Maladaptive solution, 20-21
Management styles of AIDS patients, 353-355
Marginal families, 240-245, 260-262
definition of, 241
Marginal families is crisis, 239-264
sick role, 245-256
vulnerable populations, 256-260
Marker events, 64, 66
Medicare/Medicaid, 218-219
Mental health workers, 438-439
Middle-aged adults in crisis, 165-197
adoptive parents, 191-193
divorce, 165-181
post-parental issues, 193-194
remarriage, 183-191
Minimization, definition of, 10
Misdiagnosed post-traumatic stress disorder, 379
Moral development stages (Kohlberg), 113-116
Moral judgment and adolescents, 113-116
Moratorium and identity, 127
Mothers without custody, 179-181
Mourning, 25
Multidisciplinary team, definition of, 433
Multiple trauma, 401-429
caregivers, 419-429
N
Nature of crisis, 3-15
chronology of, 8-12
contributors to theory, 6
etiology, 3-6
Nature reality testing, 6-8
Neglect, definition of, 266
No-fault divorce legislation, 172
Nursing homes (see Care facilities)
O
Object permanence, 96
Occupational stress, 143-145
Outcomes of crisis, 17-18, 74
evaluation of, 75-76
Overgeneralization, definition of, 10
Overidentification with troubled person, 11
P
Panic, 47
Parameters of crisis, 17-38
classification of, 18-19
Page 453
R
Rape, 387-397
counseling, 393-395
support system, 391-393
Rape trauma syndrome, 388
Rationalization, definition of, 7
Reaction formation, definition of, 7
Reaction phases of disaster, 323-325
Reality testing and crisis, 6-8
Reciprocal emotion, 45
Referrals, 11, 32, 51
Regression, definition of, 7
Relocation crises and the elderly, 210-212
Remarriage, 183-191
stepchildren, 186-188
stepparents, 184-186
Response to violence, 298-299
Repression, definition of, 7
Residential care facilities, 216
Retirement crises, 203-210
Risk taking and young adults, 146-147
Role playing as training technique, 442
Role portrayal as training technique, 442
Role reorganization in response to disaster, 322-323
S
School-based clinics for adolescents, 119-120
Secondary crisis prevention, 33-34
Selective concentration, definition of, 10
Self-esteem through love-sex relationships, 120-121
Self-fulfilling prophecy, 45
Self-help organizations, 31, 34 (see also Support group)
Sensorimotor stage of development, 96
Separation vs. divorce, 167-168
Separation anxiety, 46-47
separation from mother, 90
separation from parent, 169
Sexual abuse:
and battered women, 300-301
of boys, 280
of child, 277-282
Sexual-reproductive decisions of young adults, 141-143
Sexuality in adolescence, 117-125
Sibling incest, 281
Sick role, family response to, 245-247
Signal anxiety, 46
Significant others, trauma as crisis, 410-419
Single parent, 179
Situational crises, 18-19, 67
Skilled nursing facilities, 216-217
Social disapproval of working mothers, 156
Sociological formulations and wife beating, 296
Somatic changes and adolescents, 116-117
Spouse abuse, 289-310
alcohol and violence, 294-295
battered women, 291-294, 300-309
theoretical explanations, 295-299
violent husbands, 291-294
violent wives, 299-300
Statutory rape, definition of, 391
Stepchildren, 186-191
Stepfathers and child sexual abuse, 278-279
Stepparents, 184-186, 188-191
Stigma of AIDS, 345-346
Stress: