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.     

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.     

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.     

The long-term evaluation of a behavioral treatment program for child molesters

Recidivism data derived from various sources over a follow-up period of 1–11 yr, provided the basis for appraising the effectiveness of a comprehensive cognitive-behavioral treatment program for familial and nonfamilial child molesters. Unofficial records held by police and Children's Aid Societies proved to be the best data for estimating recidivism. These data revealed increases in recidivism with longer follow-up periods, but there were consistent advantages for the treated over the untreated patients. Men who had sexually abused the daughters of other people demonstrated the clearest treatment benefits. The younger offenders and those who had engaged in genital-genital contact with their victims were more likely to reoffend even if they were treated. Contrary to the expectations of behavior therapists, indices of deviant sexual preferences did not predict outcome.