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.     

Delinquent youths and family

This study investigates the relationship of several demographic variables, family structure (number of siblings in house, family intactness, sibling rank, number of persons in household) and family environment (family relationship, personal growth, and family system maintenance). The family environment variables are dimensions of the Family Environment Scale (Moos, 1974). The subjects reported a fairly good reliability on the scale (Cronbach's alpha = .753). The data collection for the present study represents 198 youths: 68 official chronic delinquents and 130 official nondelinquents. A discriminant analysis was used to determine which of the demographic and family environment variables had the most predictive power in discriminating between the groups. The general analysis indicated that ten of the variables explained 49% of the variance between the chronic delinquent and nondelinquent groups. Personal growth was found to have the most discriminating power, followed by number of siblings, race, sex, and system maintenance.     

Psychoanalysis, marital therapy, and object-relations theory

This paper attempts to indicate why psychoanalysts should be interested in marital therapy. It discusses the clinical advantages and disadvantages of marital therapy as compared to psychoanalysis, describes the contributions of the classical psychoanalytic viewpoint to marital therapy, and finally, attempts to complement the classical psychoanalytic viewpoint with an object-relations viewpoint which can illuminate marital dynamics and provide interpretive content during the course of marital therapy.     

Transference across gender lines

Four clinical examples of oedipal-based transference across gender lines are presented with the aim of illustrating (1) its existence, (2) the defenses against its emergence, and (3) the use of the analyst's gender as both an organizer of and resistance to certain transference manifestations. Factors that contribute to the availability for analysis of cross-gender transference are discussed, as are the resistances and other obstacles to its actualization.