Ecology of Abusive and Nonabusive Families Implications for Intervention
Alberto C. Serrano, M.D., Margot B. Zuelzer, Ph.D., Don D. Howe, M.D., and Richard E . Reposa, M.S. W.
Abstract , The authors compare family interaction in 70 child abuse cases and 70 nonabuse
psychiatric outpatient cases. The children were matched for age level (3·6, 6-12, and 12-17 years), sex, and primary diagnostic impression. Specific parameters focused on within each family included chronic situational stress, income level, mobility, previous psychiatric treatment, family conflict, husband-wife co nflict, divorce. family resources, parent-child interaction, and underlying contributory factors with the parent and/or child . Abusive families were uniformly found to show a higher degree of pathology along the same parameters compared with controls. The significance of treating abusive families in the context of social systems is discussed.
In recent years, child abuse has come to be considered a severe community problem which pervades all socioeconomic levels and ethnic groups. It appears that abuse is most often perpetrated within families between parents and children. The substrate for abuse lies within the personality characteristics of the abuser and the abused. It is often triggered by environmental stress factors. Because of the complex nature of abuse, there has been a tendency by researchers and clinicians to move from interpretations of single
Dr. Sl'TTano is Professor of Psychiatry and Pediatrics and Director of the Division of Child and Adolescent Psychiatry at the University of Texas Health. Science Center at San Antonio, and Executive Director of the Community Guidance Center of Bexar County. Dr. Zuelzer is Assistant Professor of Psychology and a child psychologist, and Dr. Howe is Assistant Professor of Psychiatry and a child psychiatrist, both at the University of Texas Health. Science Center and the Community Guidance Center. Mr. Reposa is Social Work Supervisor and Department of Human Resources Special Projects Coordinator at the Community Guidance Center. The authors would like to express their appreciation to Mr. Robin Morris f or his valuable assistance in gathering and correlating the statistical data in this study. Reprints ma.~ be requested from Dr. Serrano at the Community Guidance Center of Bexar County, 2135 Babcock Road, San Antonio, TX 78229.
0002-7 I38/7!1/1 80 1-067 $00.88 e 1979 American Academy of Child Psychiatry.
67
68
Alberto C. Serrano et al.
dimensions, such as biological, psychological, social, economic, to consider a multidimensional view of the phenomenon . Many clinically oriented child abuse programs are presently looking at what is known as the "dynamics of abuse," including the parent-child relationship, the parents' own childhood experiences, the parents' personality dynamics, the quality of the marital relationship, and the availability of a supportive network. Although as yet unsupported by controlled research findings, these d ynamics nevertheless seem to represent a clinical syndrome which has implications for evaluation, diagnosis, and treatment of abusive families. Green (1976) addresses himself to implications for treatment of abusive families. He advocates a multidisciplinary approach (not necessarily psychiatric) where he involves the parent in a corrective emotional experience with an accepting, gratifying, uncritical adult who gives continuous reassurance and support during initial states of the treatment. The parents' own basic dependency needs must be gratified before "demands" can be placed on them. The therapeutic focus on the abused child needs a gradual and cautious approach to prevent the unleashing of jealousy and competitiveness on the part of the parent. The purpose of this st udy is to examine patterns of family interaction in 70 cases of child abuse and to discuss the implications for the treatment of the famil y. These 70 cases were matched with 70 nonabusive clinic cases for age level, sex, and primary diagnosis. Gil's hypothesis (1968) is tested that there is no absolute qualitative difference between abusers and nonabusers, but a difference in degree of pathology. METHOD
The 70 abusive families referred to the team had alread y come under the supervision of the Department of Human Resources (DHR) because of verified chronic abuse and/or neglect. The work-up involves taking an extensive family history and making detailed observations on family interaction. A "split" team-family evaluation approach is used (i.e., family members are interviewed together and separately by the team members. This may include parents together, parents separately, siblings together, siblings separately, etc.). (For a detailed description of the team-family approach , see Serrano, 1974.) After the evaluation, the team and the DHR worker meet in a debriefing to discuss the famil y dynamics . Specific recommendations for further disposition and treatment
Ecology of Abusive and Nonabusive Families
69
are made. Relevant risk factors are weighed and considered, especially the parents' capacity for change. Disposition is discussed with the DHR worker within the framework of the legal and social realities of the community. A detailed treatment plan is formulated, and efforts are made to involve the extended ecological system of the child and family. The 70 families used in the control group were taken from the files of the Community Guidance Center, a psychiatric outpatient clinic for children and adolescents. This clinic has a family and social systems orientation. Referrals come from all economic strata and all ethnic groups representative of the local community. The overwhelming majority of cases seek help voluntarily. Seven areas of family dynamics were rated on a 4-point scale for degree of severity. These were: (1) primary pathology; (2) family motivation to change; (3) husband-wife conflict; (4) family harmony; (5) parents' sensitivity to child's needs and capabilities; (6) parents' capacity to manage child's behavior; and (7) overinvolvement/underinvolvernent.' FINDINGS
Factors Across Age Groups
Some common factors emerged across age groups with regard to abused children and their families. It should be noted, however, that although matched for age, sex, and primary diagnosis, the abuse sample and its controls could not be matched for income level. Both low- and middle-income abusing families showed severe disturbance in functioning, e.g., lack of motivation for change, marital discord, and lack of sensitivity to the child's needs. In the control group, however, only low-income families ($0-7,999) showed severe disturbance in functioning, in contrast to middle-income control families. who showed mild to moderate disturbances. These findings underline Elmer's (1977) hypothesis that the stress and privation of lower-class membership may be as potent a factor as abuse in determining disturbed family interaction. Disturbed family interaction in the abuse sample took the form of chronic and intense conflict between children and parents, and between marital partners. Multiple separations, divorces, and reI A detailed definition of terms used in the rating scale will be given upon rcqucst of the authors,
70
Alberto C. Serrano et al.
marriages were interspersed with verbal and physical battles. Often the children were drawn into these quarrels and locked into a no-win position, where everyone tended to lose. Abusive families showed repeated efforts to maintain dysfunctional family and marital ties. One or more of the parents tended to be severely overinvolved by often looking to the child for gratification of excessive dependency needs in a classic "role reversal" style. They tended to project their own feelings, and acted on their ambivalence by being punitive, rigid, overcontrolling, inconsistent, and arbitrary. They showed little or no sensitivity to the child's needs, and were unable to manage the child's behavior in a consistent and nurturant fashion. The disturbance in family interaction appeared to manifest Table I Patient and Family Characteristics of Abuse/Control Subjects (Percentage rated or answering at each age and level) 140) (N
=
3-6 years
6-12 years
Mild child
0/10
3/3
0/20
Moderate child Mild family Moderate family Severe family
5/5 0/20 30/65 65/0 21.58"
3/32 7/27 30/32 57/6 23.46"
0/30 0/15 20/20 80/15 21.89"
0/0 10/75 5.">/25 35/0 19.19"
0/3 7/57 50/33 43/7 21.91"
0/5 10/65 30/15 60/15 15.47"
0/6 0/28 100/66 7.56"
0/4 10/52 90/44 13.65"
0/11 15/47 85/42 8.22"
0/15 .">/40 35/40 60/5 17.82"
0/0 3/23 33/57 63/20 13.07"
0/0 5/20
12+ years
Primary Pathology
X· Family Motivation for Change Exceptional Average Limited Little or no
x·
Husband-Wife Conflict Mild Moderate Severe
x·
Family Harmony Appropriate Mild Moderate Severe
X· Key:
10/22 = 10% of Abused Sample/22% of Control Sample b = P < .001 p < .05 (3-6 N = 20/20; 6-12 N = 30/110; 12+ N = 20/20)
"=
20/.~O
75/30 8.23"
Ecology of Abusive and Nonabusive Families
71
itself in different ways dependent upon the age of the child. Father-(or stepfather-)child overinvolvement in over half of the teen-age sample involved sexual abuse. It occurred across low- and middle-income levels, with our study showing 47% in the less than $4,000 income group and 29% in the $16,000-20,000 income level. Three of these families were promiscuous across generational lines, with grandfather and father as well as male siblings involved. In all cases, there was overt or covert chronic conflict between husband and wife. The mother was seen as being in collusion by staying underinvolved and using massive denial. The children tended to be chronically depressed, and signaled their distress through runaway, poor peer relationship, and delinquent behavior. Most of these teen-agers had been forced to submit to sexual abuse since latency age, but chose not to reveal the involvement for fear of breaking up the family, or to protect other siblings. Some of the girls, although feeling guilty over the involvement, were clearly ambivalent because closeness to their fathers was their only source of warmth in a cold, rejecting, and "conditional" family relationship. These adolescents would finally confide in a relative, neighbor, teacher, counselor, or friend after a seemingly minor altercation with the father. Reaction by the parents at exposure ranged from denial to ambivalence to acquiescence. The mother tended to be upset, disbelieving, and primarily angry with the adolescent for "blowing the whistle" on the father. Most control sample families differed in degree of disturbed interaction as well as in the resources, external and internal, which were available to their family units for resolution of interactional difficulties. Overinvolved nonabusive mothers tended to be moderately overcontrolling with their children, often seeing them as "the problem" when they tried to become more independent and thereby threatened the family equilibrium. Interestingly enough, the majority (65%) of control group fathers tended to be underinvolved with their teen-agers. Although this may reflect the work
ethic of the primarily middle-class control sample, it may also be a reflection of the general distancing of fathers from their maturing children. In contrast to the majority of abusive families, internal resources could be utilized during treatment so that parents were able to use each other to manage the children's behavior more appropriately, provide more consistent structure, and take responsibility for assisting the children in constructive conflict resolution.
Alberto C. Serrano et al.
72 Table 2
Clinical Ratings of Problem Areas of Abused/Control Subjects (Percentage rated by each age and severity level) (N = 140) 3-6 years Parents' Sensitivity to Child's Needs & Capabilities Appropriate Mild Moderate Severe
X" Parents' Capacity to Manage Child's Behavior Appropriate Mild Moderate Severe
X" Overinvolvement Mild Moderate Severe
X" Underinvolvement Mild Moderate Severe
X" Key:
6-12 years
12+ years
0/10 10/45 30/45 60/0 19.05b
0/7 14/23 14/53 72/17 19.85b
0/10 0/35 20/45 80/10 21.81b
0/5 0/10 30/85 70/0 22.6b
0/7 13/17 17/66 70/10 24.61b
0/5 0/20 15/40 85/35 11.44"
0/0 7/100 93/0 26.26b
0/8 9/71 91/21 22.80b
0/21 0/64 100/14 25.59b
0/20 10/60 90/20 10.03"
0/37 9/53 91flO 26.99b
0/0 43/55 57/45 0.50
10/22 = 10% of Abused Sample/22% of Control Sample b=p .001 "=p .01 (3-6 N = 20/20; 6-12 N = 30/30; 12+ N = 20/20)
>
>
Family and Social Systems Intervention It is commonly accepted that the family is the basic social unit that supports the affective and instrumental needs of its members. Lewis et al. (1976) and Beavers (1977) state that healthy families present a strong parental coalition, demonstrate open and clear communications among their members, and are able to share feelings openly with a predominance of positive affect. These families seem to have a wide repertoire of adaptive coping patterns and the ability to face crises creatively. They show respect for the autonomy of their members, along with a strong sense of solidarity. In our experience, healthy families are also able to recognize and to re-
Ecology of Abusive and Nonabusioe Families
73
spect the basic developmental needs of children and adults and seem able to make flexible adjustments to family changes of equilibrium. Typically, these families have functional social networks (extended family, friends, neighbors, associates) which represent significant natural sources of emotional and instrumental support. These families also seem able to use well a broad range of community resources, including health, legal, religious, educational, and recreational social agents and agencies which are additional natural support systems. In marked contrast, most abusive families present serious evidence of internal dysfunction and of social isolation. Often, many of the instrumental functions normally expected from families have been taken over by outside social agents. They also show considerable depletion of internal emotional resources and coping skills. Control families in our study tended to fall in a midrange category. Even when they presented various degrees of impairment, they usually possessed more areas of strength than the abusing families. This consideration is of crucial value in formulating a treatment plan. Most of the control families were able to respond favorably to the relatively brief but intensive (10 to 12 sessions over a 6-month period) family therapy offered at the Community Guidance Center. In contrast, abusing families presented a picture in which the needs of the parents were primary to those of the children, often with enmeshment and blurring of generational boundaries. Even when the team was able to recognize some internal and external strengths, they could be mobilized only with considerable network coordination and over a longer period of time. Special Issues in the Treatment of Abusing Families Let us remember that abusive families enter treatment under external pressure. On behalf of the child, the Protective Services worker joins the family to gather information that potentially may be incriminating to the adults and even the minors in the family. There are major transference and countertransference problems precipitated by this intervention. It has been well established that with a specialized program, most of the abusive families can be greatly assisted, if not rehabilitated (justice and Justice, 1976). Green (1976) recommended that, when necessary, psychiatric evaluations be performed independent of Protective Services per-
74
Alberto C. Serrano et al.
sonnet. We have found it most effective to have a multidisciplinary mental health team work along with the DHR staff. The team catalyzes the mobilization of a wide variety of supportive interventions aimed at enhancing the parents' competence with a variety of therapeutic, educational, and practical approaches. Several specific aspects in our approach need further amplification. First, the abuse team includes the traditional disciplines and is available under contract by the regional unit of Protective Services, DHR, to consult with the staff and to assess and treat abusing families that have come under their supervision. The DHR worker is the case manager and is assisted by the child abuse team in close collaboration. The worker is also encouraged to use the professional support of additional health, social, educational, and legal agents which can be mobilized as part of the network of community resources. By catalyzing the coordination of efforts of existing supports and facilitating the development of new ones, it is possible to make available a broad spectrum of therapeutic resources to assist the abusing families in their rehabilitation. Most abusing families are long-term, frustrating cases which are often a countertransference challenge. Even experienced clinicians struggle between not fostering excessive dependence or not precipitating premature terminations after some initial improvement, in the attempt not to act out their impatience and frustration in response to family resistance. "Burn-out," a major problem with workers, is often relieved when consultation and teamwork are regularly available. Clinicians need to recognize existing and potential healing resources that can be mobilized in individuals, families, and their natural social matrices. It is useful to know that abusing families often perceive "helpers" as abusing them. Indeed, their frequent demandingness, ambivalence, irresponsibility, and fragility make them easy targets for "professional abuse and neglect," which is less frequent in the control families. The intervention model requires open and frequent communication across the social network. The incidence of interagency conflict (health care, educational, welfare, judicial, and others) has been surprisingly limited. Open communication, enthusiasm, considerable stamina and optimism, along with a good sense of humor, are seen as essential ingredients in maintaining the team's mental health as its members deal with highly complex families, most of whom are slow in achieving noticeable gains. It is essential that the clinicians be clear about the boundaries of their role and their authority as they introduce themselves to the
Ecology of Abusive and Nonabusive Families
75
family as a support system that can assist the family in mobilizing potential resources. While the engagement of families is always technically complex, for these families to accept treatment is in itself a corrective emotional experience. We need to recognize and respect that most abusing families will initially resist the coercive aspects of the therapeutic engagement. Emphasis needs to be shifted toward family advocacy before the family starts to accept the team as a helping resource. This emphasis is essential to assess existing and potential strengths as well as liabilities. It is also important for the team to maintain enough objectivity so as to recognize when families are not improving their parenting skills and are unwilling or unable to change toward providing a home safe enough for the children. Clinicians also need to be comfortable in the management of foster care and adoption when indicated. SUMMARY
The experiences of this study tend to support Gil's hypothesis that there are mainly differences in degree between abusing and control families. Due to the limited ability of abusive families to use internal and external resources, it is more effective to intervene through the social system to mobilize an extensive family-rehabilitative network. In addition to providing direct therapeutic intervention, the team assumes the role of facilitator, with the DHR worker as case convenor.
REFERENCES BEAVERS, W. R. (1977), Psychotherapy and Growth. New York: Brunner/Mazel. ELMER, E. (1977), A follow-up study of traumatized children. Pediatrics, 59:273-280. Gn., D. (1968), Legally reported child abuse. In: Social Work Practice, 1968. New York: Columbia University Press, pp. 135-158. GREEN, A. H. (1976), A psychodynamic approach to the study and treatment of childabusing parents. This Journal, 15:414-429. JUSTICE, B. & '/USTICt:, R. (1976), The Abusing Family. New York: Human Sciences Press. Lt:wts,.J. M., BEAVERS, W. R., GOSSETT,.J. T., & PHII.LlPS, V. A. (1976), No Single Thread. New York: Brunner/Mazel. SERRANO, A. C. (1974), Multiple impact therapy. In: Techniques and Approaches to Marital and Family Counseling, cd. R. E. Hardy & J. B. Cull. Springfield: Charles C Thomas, pp. 143-159.
Alberto C. Serrano, M.D., Margot B. Zuelzer, Ph.D., Don D. Howe, M.D., and Richard E . Reposa, M.S. W.
Abstract , The authors compare family interaction in 70 child abuse cases and 70 nonabuse
psychiatric outpatient cases. The children were matched for age level (3·6, 6-12, and 12-17 years), sex, and primary diagnostic impression. Specific parameters focused on within each family included chronic situational stress, income level, mobility, previous psychiatric treatment, family conflict, husband-wife co nflict, divorce. family resources, parent-child interaction, and underlying contributory factors with the parent and/or child . Abusive families were uniformly found to show a higher degree of pathology along the same parameters compared with controls. The significance of treating abusive families in the context of social systems is discussed.
In recent years, child abuse has come to be considered a severe community problem which pervades all socioeconomic levels and ethnic groups. It appears that abuse is most often perpetrated within families between parents and children. The substrate for abuse lies within the personality characteristics of the abuser and the abused. It is often triggered by environmental stress factors. Because of the complex nature of abuse, there has been a tendency by researchers and clinicians to move from interpretations of single
Dr. Sl'TTano is Professor of Psychiatry and Pediatrics and Director of the Division of Child and Adolescent Psychiatry at the University of Texas Health. Science Center at San Antonio, and Executive Director of the Community Guidance Center of Bexar County. Dr. Zuelzer is Assistant Professor of Psychology and a child psychologist, and Dr. Howe is Assistant Professor of Psychiatry and a child psychiatrist, both at the University of Texas Health. Science Center and the Community Guidance Center. Mr. Reposa is Social Work Supervisor and Department of Human Resources Special Projects Coordinator at the Community Guidance Center. The authors would like to express their appreciation to Mr. Robin Morris f or his valuable assistance in gathering and correlating the statistical data in this study. Reprints ma.~ be requested from Dr. Serrano at the Community Guidance Center of Bexar County, 2135 Babcock Road, San Antonio, TX 78229.
0002-7 I38/7!1/1 80 1-067 $00.88 e 1979 American Academy of Child Psychiatry.
67
68
Alberto C. Serrano et al.
dimensions, such as biological, psychological, social, economic, to consider a multidimensional view of the phenomenon . Many clinically oriented child abuse programs are presently looking at what is known as the "dynamics of abuse," including the parent-child relationship, the parents' own childhood experiences, the parents' personality dynamics, the quality of the marital relationship, and the availability of a supportive network. Although as yet unsupported by controlled research findings, these d ynamics nevertheless seem to represent a clinical syndrome which has implications for evaluation, diagnosis, and treatment of abusive families. Green (1976) addresses himself to implications for treatment of abusive families. He advocates a multidisciplinary approach (not necessarily psychiatric) where he involves the parent in a corrective emotional experience with an accepting, gratifying, uncritical adult who gives continuous reassurance and support during initial states of the treatment. The parents' own basic dependency needs must be gratified before "demands" can be placed on them. The therapeutic focus on the abused child needs a gradual and cautious approach to prevent the unleashing of jealousy and competitiveness on the part of the parent. The purpose of this st udy is to examine patterns of family interaction in 70 cases of child abuse and to discuss the implications for the treatment of the famil y. These 70 cases were matched with 70 nonabusive clinic cases for age level, sex, and primary diagnosis. Gil's hypothesis (1968) is tested that there is no absolute qualitative difference between abusers and nonabusers, but a difference in degree of pathology. METHOD
The 70 abusive families referred to the team had alread y come under the supervision of the Department of Human Resources (DHR) because of verified chronic abuse and/or neglect. The work-up involves taking an extensive family history and making detailed observations on family interaction. A "split" team-family evaluation approach is used (i.e., family members are interviewed together and separately by the team members. This may include parents together, parents separately, siblings together, siblings separately, etc.). (For a detailed description of the team-family approach , see Serrano, 1974.) After the evaluation, the team and the DHR worker meet in a debriefing to discuss the famil y dynamics . Specific recommendations for further disposition and treatment
Ecology of Abusive and Nonabusive Families
69
are made. Relevant risk factors are weighed and considered, especially the parents' capacity for change. Disposition is discussed with the DHR worker within the framework of the legal and social realities of the community. A detailed treatment plan is formulated, and efforts are made to involve the extended ecological system of the child and family. The 70 families used in the control group were taken from the files of the Community Guidance Center, a psychiatric outpatient clinic for children and adolescents. This clinic has a family and social systems orientation. Referrals come from all economic strata and all ethnic groups representative of the local community. The overwhelming majority of cases seek help voluntarily. Seven areas of family dynamics were rated on a 4-point scale for degree of severity. These were: (1) primary pathology; (2) family motivation to change; (3) husband-wife conflict; (4) family harmony; (5) parents' sensitivity to child's needs and capabilities; (6) parents' capacity to manage child's behavior; and (7) overinvolvement/underinvolvernent.' FINDINGS
Factors Across Age Groups
Some common factors emerged across age groups with regard to abused children and their families. It should be noted, however, that although matched for age, sex, and primary diagnosis, the abuse sample and its controls could not be matched for income level. Both low- and middle-income abusing families showed severe disturbance in functioning, e.g., lack of motivation for change, marital discord, and lack of sensitivity to the child's needs. In the control group, however, only low-income families ($0-7,999) showed severe disturbance in functioning, in contrast to middle-income control families. who showed mild to moderate disturbances. These findings underline Elmer's (1977) hypothesis that the stress and privation of lower-class membership may be as potent a factor as abuse in determining disturbed family interaction. Disturbed family interaction in the abuse sample took the form of chronic and intense conflict between children and parents, and between marital partners. Multiple separations, divorces, and reI A detailed definition of terms used in the rating scale will be given upon rcqucst of the authors,
70
Alberto C. Serrano et al.
marriages were interspersed with verbal and physical battles. Often the children were drawn into these quarrels and locked into a no-win position, where everyone tended to lose. Abusive families showed repeated efforts to maintain dysfunctional family and marital ties. One or more of the parents tended to be severely overinvolved by often looking to the child for gratification of excessive dependency needs in a classic "role reversal" style. They tended to project their own feelings, and acted on their ambivalence by being punitive, rigid, overcontrolling, inconsistent, and arbitrary. They showed little or no sensitivity to the child's needs, and were unable to manage the child's behavior in a consistent and nurturant fashion. The disturbance in family interaction appeared to manifest Table I Patient and Family Characteristics of Abuse/Control Subjects (Percentage rated or answering at each age and level) 140) (N
=
3-6 years
6-12 years
Mild child
0/10
3/3
0/20
Moderate child Mild family Moderate family Severe family
5/5 0/20 30/65 65/0 21.58"
3/32 7/27 30/32 57/6 23.46"
0/30 0/15 20/20 80/15 21.89"
0/0 10/75 5.">/25 35/0 19.19"
0/3 7/57 50/33 43/7 21.91"
0/5 10/65 30/15 60/15 15.47"
0/6 0/28 100/66 7.56"
0/4 10/52 90/44 13.65"
0/11 15/47 85/42 8.22"
0/15 .">/40 35/40 60/5 17.82"
0/0 3/23 33/57 63/20 13.07"
0/0 5/20
12+ years
Primary Pathology
X· Family Motivation for Change Exceptional Average Limited Little or no
x·
Husband-Wife Conflict Mild Moderate Severe
x·
Family Harmony Appropriate Mild Moderate Severe
X· Key:
10/22 = 10% of Abused Sample/22% of Control Sample b = P < .001 p < .05 (3-6 N = 20/20; 6-12 N = 30/110; 12+ N = 20/20)
"=
20/.~O
75/30 8.23"
Ecology of Abusive and Nonabusive Families
71
itself in different ways dependent upon the age of the child. Father-(or stepfather-)child overinvolvement in over half of the teen-age sample involved sexual abuse. It occurred across low- and middle-income levels, with our study showing 47% in the less than $4,000 income group and 29% in the $16,000-20,000 income level. Three of these families were promiscuous across generational lines, with grandfather and father as well as male siblings involved. In all cases, there was overt or covert chronic conflict between husband and wife. The mother was seen as being in collusion by staying underinvolved and using massive denial. The children tended to be chronically depressed, and signaled their distress through runaway, poor peer relationship, and delinquent behavior. Most of these teen-agers had been forced to submit to sexual abuse since latency age, but chose not to reveal the involvement for fear of breaking up the family, or to protect other siblings. Some of the girls, although feeling guilty over the involvement, were clearly ambivalent because closeness to their fathers was their only source of warmth in a cold, rejecting, and "conditional" family relationship. These adolescents would finally confide in a relative, neighbor, teacher, counselor, or friend after a seemingly minor altercation with the father. Reaction by the parents at exposure ranged from denial to ambivalence to acquiescence. The mother tended to be upset, disbelieving, and primarily angry with the adolescent for "blowing the whistle" on the father. Most control sample families differed in degree of disturbed interaction as well as in the resources, external and internal, which were available to their family units for resolution of interactional difficulties. Overinvolved nonabusive mothers tended to be moderately overcontrolling with their children, often seeing them as "the problem" when they tried to become more independent and thereby threatened the family equilibrium. Interestingly enough, the majority (65%) of control group fathers tended to be underinvolved with their teen-agers. Although this may reflect the work
ethic of the primarily middle-class control sample, it may also be a reflection of the general distancing of fathers from their maturing children. In contrast to the majority of abusive families, internal resources could be utilized during treatment so that parents were able to use each other to manage the children's behavior more appropriately, provide more consistent structure, and take responsibility for assisting the children in constructive conflict resolution.
Alberto C. Serrano et al.
72 Table 2
Clinical Ratings of Problem Areas of Abused/Control Subjects (Percentage rated by each age and severity level) (N = 140) 3-6 years Parents' Sensitivity to Child's Needs & Capabilities Appropriate Mild Moderate Severe
X" Parents' Capacity to Manage Child's Behavior Appropriate Mild Moderate Severe
X" Overinvolvement Mild Moderate Severe
X" Underinvolvement Mild Moderate Severe
X" Key:
6-12 years
12+ years
0/10 10/45 30/45 60/0 19.05b
0/7 14/23 14/53 72/17 19.85b
0/10 0/35 20/45 80/10 21.81b
0/5 0/10 30/85 70/0 22.6b
0/7 13/17 17/66 70/10 24.61b
0/5 0/20 15/40 85/35 11.44"
0/0 7/100 93/0 26.26b
0/8 9/71 91/21 22.80b
0/21 0/64 100/14 25.59b
0/20 10/60 90/20 10.03"
0/37 9/53 91flO 26.99b
0/0 43/55 57/45 0.50
10/22 = 10% of Abused Sample/22% of Control Sample b=p .001 "=p .01 (3-6 N = 20/20; 6-12 N = 30/30; 12+ N = 20/20)
>
>
Family and Social Systems Intervention It is commonly accepted that the family is the basic social unit that supports the affective and instrumental needs of its members. Lewis et al. (1976) and Beavers (1977) state that healthy families present a strong parental coalition, demonstrate open and clear communications among their members, and are able to share feelings openly with a predominance of positive affect. These families seem to have a wide repertoire of adaptive coping patterns and the ability to face crises creatively. They show respect for the autonomy of their members, along with a strong sense of solidarity. In our experience, healthy families are also able to recognize and to re-
Ecology of Abusive and Nonabusioe Families
73
spect the basic developmental needs of children and adults and seem able to make flexible adjustments to family changes of equilibrium. Typically, these families have functional social networks (extended family, friends, neighbors, associates) which represent significant natural sources of emotional and instrumental support. These families also seem able to use well a broad range of community resources, including health, legal, religious, educational, and recreational social agents and agencies which are additional natural support systems. In marked contrast, most abusive families present serious evidence of internal dysfunction and of social isolation. Often, many of the instrumental functions normally expected from families have been taken over by outside social agents. They also show considerable depletion of internal emotional resources and coping skills. Control families in our study tended to fall in a midrange category. Even when they presented various degrees of impairment, they usually possessed more areas of strength than the abusing families. This consideration is of crucial value in formulating a treatment plan. Most of the control families were able to respond favorably to the relatively brief but intensive (10 to 12 sessions over a 6-month period) family therapy offered at the Community Guidance Center. In contrast, abusing families presented a picture in which the needs of the parents were primary to those of the children, often with enmeshment and blurring of generational boundaries. Even when the team was able to recognize some internal and external strengths, they could be mobilized only with considerable network coordination and over a longer period of time. Special Issues in the Treatment of Abusing Families Let us remember that abusive families enter treatment under external pressure. On behalf of the child, the Protective Services worker joins the family to gather information that potentially may be incriminating to the adults and even the minors in the family. There are major transference and countertransference problems precipitated by this intervention. It has been well established that with a specialized program, most of the abusive families can be greatly assisted, if not rehabilitated (justice and Justice, 1976). Green (1976) recommended that, when necessary, psychiatric evaluations be performed independent of Protective Services per-
74
Alberto C. Serrano et al.
sonnet. We have found it most effective to have a multidisciplinary mental health team work along with the DHR staff. The team catalyzes the mobilization of a wide variety of supportive interventions aimed at enhancing the parents' competence with a variety of therapeutic, educational, and practical approaches. Several specific aspects in our approach need further amplification. First, the abuse team includes the traditional disciplines and is available under contract by the regional unit of Protective Services, DHR, to consult with the staff and to assess and treat abusing families that have come under their supervision. The DHR worker is the case manager and is assisted by the child abuse team in close collaboration. The worker is also encouraged to use the professional support of additional health, social, educational, and legal agents which can be mobilized as part of the network of community resources. By catalyzing the coordination of efforts of existing supports and facilitating the development of new ones, it is possible to make available a broad spectrum of therapeutic resources to assist the abusing families in their rehabilitation. Most abusing families are long-term, frustrating cases which are often a countertransference challenge. Even experienced clinicians struggle between not fostering excessive dependence or not precipitating premature terminations after some initial improvement, in the attempt not to act out their impatience and frustration in response to family resistance. "Burn-out," a major problem with workers, is often relieved when consultation and teamwork are regularly available. Clinicians need to recognize existing and potential healing resources that can be mobilized in individuals, families, and their natural social matrices. It is useful to know that abusing families often perceive "helpers" as abusing them. Indeed, their frequent demandingness, ambivalence, irresponsibility, and fragility make them easy targets for "professional abuse and neglect," which is less frequent in the control families. The intervention model requires open and frequent communication across the social network. The incidence of interagency conflict (health care, educational, welfare, judicial, and others) has been surprisingly limited. Open communication, enthusiasm, considerable stamina and optimism, along with a good sense of humor, are seen as essential ingredients in maintaining the team's mental health as its members deal with highly complex families, most of whom are slow in achieving noticeable gains. It is essential that the clinicians be clear about the boundaries of their role and their authority as they introduce themselves to the
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family as a support system that can assist the family in mobilizing potential resources. While the engagement of families is always technically complex, for these families to accept treatment is in itself a corrective emotional experience. We need to recognize and respect that most abusing families will initially resist the coercive aspects of the therapeutic engagement. Emphasis needs to be shifted toward family advocacy before the family starts to accept the team as a helping resource. This emphasis is essential to assess existing and potential strengths as well as liabilities. It is also important for the team to maintain enough objectivity so as to recognize when families are not improving their parenting skills and are unwilling or unable to change toward providing a home safe enough for the children. Clinicians also need to be comfortable in the management of foster care and adoption when indicated. SUMMARY
The experiences of this study tend to support Gil's hypothesis that there are mainly differences in degree between abusing and control families. Due to the limited ability of abusive families to use internal and external resources, it is more effective to intervene through the social system to mobilize an extensive family-rehabilitative network. In addition to providing direct therapeutic intervention, the team assumes the role of facilitator, with the DHR worker as case convenor.
REFERENCES BEAVERS, W. R. (1977), Psychotherapy and Growth. New York: Brunner/Mazel. ELMER, E. (1977), A follow-up study of traumatized children. Pediatrics, 59:273-280. Gn., D. (1968), Legally reported child abuse. In: Social Work Practice, 1968. New York: Columbia University Press, pp. 135-158. GREEN, A. H. (1976), A psychodynamic approach to the study and treatment of childabusing parents. This Journal, 15:414-429. JUSTICE, B. & '/USTICt:, R. (1976), The Abusing Family. New York: Human Sciences Press. Lt:wts,.J. M., BEAVERS, W. R., GOSSETT,.J. T., & PHII.LlPS, V. A. (1976), No Single Thread. New York: Brunner/Mazel. SERRANO, A. C. (1974), Multiple impact therapy. In: Techniques and Approaches to Marital and Family Counseling, cd. R. E. Hardy & J. B. Cull. Springfield: Charles C Thomas, pp. 143-159.
