The Heart of the Matter: An Essay about the Effects of Managed Care on Family Therapy with Children*

This essay is based on a pilot study that examined the effects of managed care on the treatment of children and families, with special attention to community mental health. We embarked on the pilot study to test the accuracy and generalizability of our impression that family therapy and other systemic practices have been marginalized in ordinary clinics and agencies, and to understand the reasons why. We interviewed managed care providers, researchers, family therapy trainers, and clinicians in the Northeast. Our findings led to seven themes that support our impression that, even though there is a consensus about the need for coordinated family-based services, there is a disconnection between state policies, contractual requirements and what is actually occurring at the implementation level. This study suggests that our knowledge of human systems may be in danger of being disqualified and lost, with damaging consequences for the care of children. Yet, as systemic thinkers and practitioners, it is our belief that ethical and effective treatment need not be at odds with care that is cost-efficient. The direction of our future research will be to study whether the involvement of all stakeholders at all levels of planning and training leads to systemic family-based practices that consistently save costs and provide high-quality care.     

Perceived parental acceptance and female juvenile delinquency

The responses of 62 adolescent females residing at a state training school and 62 high school females on a measure of perceived parental acceptance were compared while statistically controlling for mental age, chronological age, socioeconomic status, social desirability, and family structure. Generally significant (p less than .05) results indicate that incarcerated females viewed their mothers and fathers more negatively than did nonincarcerated females. Slightly more ambivalent results were indicated in the mother-daughter relationship (delinquent girls reported mothers to be more rejecting/neglecting than did nondelinquents, but no significant differences were found between the groups on perceived mother acceptance) than in the father-daughter relationship. Results were discussed in terms of reported parental differences in acceptance-nonacceptance, providing limited support for Ausubel's satellization theory of child development, and the difficulty of inferring causality from retrospective self-report studies using "captive" subjects.     

The adaptive significance of destructiveness in primitive personalities

Destructiveness in primitive personalities is not restricted to a segment of the person as it is in the case of neurotics, but is global and pervasive. This destructiveness is meaningfully configured in a manner which cannot fully be accounted for by constitutional factors or be comprehended from the individual, intrapsychic, conflictual viewpoint of classical psychoanalysis. It follows an interpersonally meaningful pattern and therefore has adaptive significance in the contemporary life of the individual. The adaptive model I propose does not violate essential canons of psychoanalytic theory, for it can simultaneously be conceptualized in terms of intrapsychic structure and dynamics. This model holds out the possibility for a therapeutic approach to primitive personality organization which differs in some but by no means all respects from classical analysis.     

Somatic response to stress, physical symptoms and health service use: The role of current stress

The study examined physical symptoms and health service utilization of subjects high or low on a measure of the tendency to experience stress somatically and high or low on a measure of current stress. High somatic responders reported greater numbers of symptoms than low somatic responders regardless of stress level. However, high somatic responders who were experiencing high levels of current stress reported significantly more symptoms than high somatic responders who were experiencing low levels of stress. These findings indicate that somatic response to stress reflects both a general tendency to focus on physical symptoms, and a specific tendency to focus more on physical symptoms when under stress. Analysis of health service records indicated that high somatic responders had more visits prompted by symptoms than low somatic responders, but did not differ in frequency of health service visits designed to maintain health. The findings further clarify the relationship between somatic response to stress, physical symptoms and health service use.