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Shv 0~ I s i A L )DJO4 SEEING THE TRUNK OF THE
PRACTICE-THEORY TREE
Keeping up with the latest individual treatment theories, a responsibility incumbent on any professional, has burgeoned into a task of overwhelming proportions in recent years. The pro- liferation of theory on personality development and functioning and on the multitude of interventive strategies boggles the mind. At times, the formulations appear to stem from varying convic- tions as to the intrinsic nature of humankind, the meaning of life, and our innate potential for mastering our own destinies. While our professional practice can draw on a more pragmatic empirical base than such philosophical positions, new practice prophets regularly mount the podium, and they never lack for milling throngs of well-travelled seekers of Truth.
Restlessness and innovation are characteristic of a relatively young profession, although the creative surge from the social and behavioral sciences has sorely tried our capacity to test and integrate new knowledge. Then, too, 'the social ferment of recent years has lent a heightened urgency to discarding the old in favor of the new. While the reaction to outmoded traditions did pro- mote independence from social controls and rediscovered a com- mitment to humanism, the pace of change precluded the delibera- tion and selectivity essential to any aspiring scientific endeavor.
Ego Psychology as Theory Base
JOHN MATUSHIMA, D.S.W. *
In harvesting the best from a cornucopia of notions and con- structs, social work is in the fortunate position of being young enough for receptivity, yet old enough to exercise some selectivity. In our view, personality theory rooted in ego psychology con- tinues to provide an enduring and growing foundation for practice, sustaining the branching applications of theoreticians such as Gordon Hamilton (1951), Helen Harris Perlman (1957), Florence Hollis (1964), and other enduring contributors to casework theory. While differences among these branches can readily be identified, there is reason to view them as deriving from a common trunk and comprising parts of a single system. Recognition of a unifying trunk may be useful, as in its absence we fall prey to the polarized passions and artificial dichotomies of the new versus the old, the
*Dr. Matushima is Associate Professor, School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio, and Visiting Associate Professor (Research), Smith College School for Social Work.
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faddist versus the hidebound, and the progressive versus the conservative.
Similarities Outweigh Differences In an effort to identify substantive differences and to set aside
long-standing "straw men," surveyors of treatment theory such as Turner (1974) and Simon (1970) found much common ground among contributors to practice knowledge. According to Turner, the commonalities in practice based on avowedly divergent theories included emphases on man in his present reality, his capacity for growth, his health and strength, his ability to reason, to take responsibility, to change as well as adjust, to reflectively plan his present and future life and to be accountable for his functioning. The weighting of these components vary, but there is more consensus than disagreement on their importance and admixture (1974, 497).
There are differences in treatment focus, but no category is the exclusive province of a single orientation, nor do others deny the pertinence of one or another factor. It is futile as well as naive, for example, to identify long-term contacts with id psychol- ogy when ego psychology has long been the undergirding of prac- tice. What social worker focuses on the unconscious and intra- psychic phenomena to the exclusion of the problem situation, family interaction, or societal distortions that affect present social functioning? Who dwells on past social history as indispensable to helping clients in any and all current circumstances?
Over and over again, (it is) evident that emphasis is on the present ... of understanding the current life situation of the client, of the client using his reasoning capacities to learn new patterns of behavior, of involving the client in the total process.... No one suggests that (long-term treatment) is the mode of all treatment ... the more general assumption was that treatment is not extensive in length ... the preva- lent theme throughout is that the focus of treatment must be on the client and his psychosocial situation and not exclusively on inner psychic functioning. Not that the instinctual and the inner life of man are overlooked, but that this component is only a part of man (Turner, 1974, 497).
One old bone of contention equates the psychoanalytic theory of personality development with psychoanalysis as treatment method, so that a student of the personality theory must therefore
:es and to set aside Lt ment theory such -h common ground ;cording to Turner, ivowedly divergent present reality, his is ability to reason, djust, to reflectively accountable for his : nts vary, but there -ir i mportance and
but no category is nor do others deny is futile as well as acts with id psychol- ndergirding of prac- : onscious and intra-
problem situation, affect present social )ry as indispensable nstances?
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PRACTICE-THEORY TREE 183
be an advocate of psychoanalysis as the only "real" treatment. Because the parameters for psychoanalytic treatment, such as free association, interpretation of dreams, are inappropriate to the circumstances of clinical social work practice, by implication, the developmental theory must also be inappropriate. The funda- mental misconception that this personality theory is synonymous with a specific treatment mode regularly arises as one of the most notorious of misinformed arguments.
Pragmatics as Priorities The position that similarities in treatment approaches are more
the rule than the exception is supported by practice experience. It is most sensible to prefer interventions that are brief, rely on cognitive techniques, and result in reasonably prompt modifica- tion of the presenting problem. Certainly not everyone who re- quests help needs self-scrutiny or personality change! And the point that concrete assistance sometimes has dramatic long-range effects on individual and family functioning-in addition to reliev- ing the immediate situation-should have been encompassed long ago in even the most esoteric of treatment settings. Dr. Douglas Bond, psychoanalyst and former Dean of the Medical School, Case Western Reserve University, often noted (in his lectures on parent-child interaction in toilet training) that the greatest single advance in mental health was the invention of the washing machine!
Where it becomes evident that conflict, relationships, learning from the past significantly handicaps social functioning, then one weighs the advisability of directing the client's attention to those areas. And it is at this level of treatment-where past and present, conscious and unconscious, emotional and rational aspects hinder current functioning-that the worker can become most easily con- fused and thereby disillusioned. Keeping paramount the steady focus on strengthening the coping capacity of the ego, one can be guided by some fundamental principles.
These principles are reiterated here because they typify treat- ment commonalities based on ego psychology, and they simul- taneously embrace issues of contention and misunderstanding in our field. These points do not comprise a complete listing, but they do illustrate the practice theory trunk that provides potential nourishment to variations and outgrowths.
18 4
The Past and the Present Together
JOHN MATUSHIMA, D.S.W.
Principle: Continuing problems may be repetitious of past conflicts in new circumstances and with substitute persons.
The primary usefulness of this principle is that the personality as well as the situation is recognized as integral to problem assess- ment. While this is a basic law in practice, emphasis in recent years has been placed on the situation-dichotomizing past and present, person and situation. While intervention may be ad- dressed only to the specifics of the situation, the rationale under- lying the worker's intervention stems from the broad perspective of personality dynamics as well.
Early developmental conflicts, ingrained by later experiences, may be reenacted in the present problem. Thus, even though the episode per se seems modifiable, the client repetitively continues to be enmeshed in the same or similar circumstances. In such instances, explanations, advice, and exhortation directed only to situational change rarely brings positive results.
The persistence, tenaciousness, and power of the past in sometimes preventing logical change cannot help but be observed in practice. This does not mean that the presenting problem is shunted aside, or that every client has the inner resiliency to be able to tolerate more than a situational contact. The client's ex- pressed discomfort as well as his commitmeUt-tnself-evaluative content provides a beginning index as to its advisability. The point is that a principle providing for dynamic understanding does not automatically stipulate "insight therapy." The inter- vention per se depends instead on the client's capacity to put up with the anxiety attendant to change, the reasons for his having sought help, and other determinants specific to the case-not the worker's recognition or denial as to the pertinence of the past in understanding current social functioning.
The presenting problem, the client's stated goals, the ingrained nature of his attitudes, or the agency purpose may well indicate short-term contacts. Time-limited contacts, too, are an alternative, or any of a range of treatment options, as the past-in-present principle is only one determinant of interventive appropriateness. If the worker truly understands the validity of the principle, how- ever, realistic goal-setting is enhanced-and unnecessary frus- tration allayed-because the treatment effort is not directed- to personality dynamics that cannot be modified under the cir- cumstances.
PRACTICE-
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PRACTICE-THEORY TREE
Resistance as a Treatment Reality
185
Principle: In problem situations where external circumstances do not prohibit change, the client's own need to retain the problem may be significant.
The pertinence of the unconscious is another old bone of con- tention among treatment theorists. In an eagerness to support the individual's capacity consciously to control problem resolution, some theoreticians literally disown the existence of the uncon- scious as an ingredient affecting social functioning. It is as if one must conceive of the individual as completely motivated by either conscious or unconscious phenomena, thereby creating another "straw man." In fact, the issue actually revolves around how one can work most purposefully with human behavior that stems from multiply-determined sources.
One clear manifestation of unconscious motivations is the phenomenon of resistance. On the face of it, it is clearly illogical; why would a client plead for change and battle against it at the same time? Tangibles such as forgetting appointments, chronic lateness, and gross denials of obvious inner stress are clear. Less apparent are rationalization, intellectualization, and isolation of affect, for example, where a client is verbally facile and appears the model of insight and intelligence. In such instances, over- looking the anxiety so efficiently held in check by the ego defenses, the worker may accept the "insight potential" at face value, plunge ahead with a blueprint organizing "significant' content," only to be dismayed when the client's behavior shows no change. Then, perhaps belatedly having become aware of the resistance, the worker inserts a series of interpretations as to the possible causes of the underlying anxiety-and is even more frustrated because the client acknowledges the worker's acumen but re- mains serenely immobilized.
The bases for the resistance may be completely unperceived by the client, although his present adaptation is grossly uncom- fortable and he avowedly desires change. Perhaps the client, indeed, is quite at ease with what may be a lifelong pattern, and there is no anxiety present. Or, for self-punitive purposes and/or protection from discomfort, the desire for change may be stymied by an equal or greater internal block against allowing himself to perceive conflictual feelings.
A vital point is the worker's appreciation of the functional imperative inherent in ego defenses. Where inner conflict exists, the client's anxiety may prevent change lest an uncomfortable
PRACTICE-THEOR
own emotions (as we skills. For the worker ties in this endeavor where linkages may that relate to the prot
In some instances, the relationship may anxiety. The results rr treatment or arrive at order to escape the fe such terminations oc, anticipated the emot cussion, has been sure places the responsibil interpretations lead peated, the worker's instead of learning he he avoids upset by si discussion of problem versus affective factor
Most experienced t well as cognitive agn goals, the pace, and nized feelings on the progress, ego psychol edge the powerful rc hope for change in t as intellectual comfoi only when the client librium is desirable. ' versus emotional det functions are stressec addressing those em( cognitive and the em( integral to the treat bring the anxiety and lem engagement, ar change that occurs as
Here and Now Plus Principle: Treatment action between client
186 JOHN MATUSHIMA, D.S.W.
equilibrium be replaced by the panic of the unknown. Inevitably, the defenses stiffen in response to the sensed anxiety, so that a frontal approach to unconscious memories, feelings, and impulses is often unsuccessful. Much more advisable, keeping the focus on the client's own initiative in controlling the pace and progress of treatment, would be curiosity directed to the manifest defenses. In this way, again, the worker places himself in alliance with the client's own self-evaluative, cognitive capacities. To the extent that the client's own push toward health is thus supported by the worker, the admissibility of further observations linking cause and effect, past and present, is enhanced.
Again, in confronting the "straw men" of false dichotomies, it is not dynamic principles that are lacking so much as a practice- honed sensitivity to the complexities of conscious and uncon- scious ego functioning.
Relationship of Cognitive and Affective Functions Principle: Treatment leads to engagement and change only when it is perceived by the client as relating to his present functioning and is accompanied by genuine feeling investment.
Another misunderstood issue concerns the relationship between cognitive and emotional aspects of treatment. Some practitioners assert 'that traditional practice theory minimizes the client's capacity to reason, understand, and utilize conscious problem- solving techniques and that undue emphasis is placed on "un- covering" unconscious motives. Whereas examples of such prac- tice are evident, ego psychology in fact supports a much broader perspective.
Sound practice does place priority on the thinking, planning, anticipating, self-observational capacities of the individual. But it also stipulates that the worker cannot be the intellectual guide who rationally resolves the problem and presents the client with a solution. The client may, in deference to the worker, learn to parrot a superficial litany of insight, but he will most likely remain unmoved and unchanged. In this sense, the client's feelings of distress, concern, and anxiety (if actually as well as avowedly present) are the very factors that promise effective moves toward change.
It is the worker's task to help the client utilize his own cognitive capacities in recognizing and understanding the presence and i mmediate bases for those anxieties. And it is this task-the indis- pensable need to help the client commit himself to confronting his
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PRACTICE-THEORY TREE
Here and Now Plus There and Then
18 7
own emotions (as well as thoughts)-that demands the worker's skills. For the worker must support the client's cognitive capaci- ties in this endeavor, and exercise the utmost tact and timing where linkages may be introduced as to unrecognized feelings that relate to the problem at issue.
In some instances, the client's commitment to the work and to the relationship may not withstand the consequent arousal of anxiety. The results may be disappointing, as the client may leave treatment or arrive at a premature "resolution" to his problem in order to escape the feelings that have become more visible. Where such terminations occur, it is possible that the worker has not anticipated the emotional vicissitudes aroused by content dis- cussion, has been surprised by the surfacing anxiety, and ruefully places the responsibility on practice theory that "promises" that interpretations lead to insight. When such experiences are re- peated, the worker's antagonism to the theory solidifies, i.e., instead of learning how to work with the phenomenon of anxiety, he avoids upset by sticking with the present and intellectualized discussion of problems. He then becomes a proponent of cognitive versus affective factors in treatment, and the dichotomy endures.
Most experienced treatment theorists would stress emotional as well as cognitive agreement between worker and client as to the goals, the pace, and the process of their efforts. Where unrecog- nized feelings on the part of either or both participants paralyze progress, ego psychologically based practice theory does acknowl- edge the powerful role of those feelings. There would be little hope for change in the absence of the client's emotional as well as intellectual comfort with the solution. The change can endure only when the client feels as well as thinks that the new equi- librium is desirable. The stance, however, is not that of cognitive versus emotional determinants of change. Rather, the cognitive functions are stressed as the avenue-the only means, really-to addressing those emotions that promote or inhibit change. The cognitive and the emotional, then, intermix and are intertwined as integral to the treatment process. Both functions combine to bring the anxiety under control, marshal it in the service of prob- lem engagement, and buttress the behavioral and attitudinal change that occurs as a result.
Principle: Treatment needs to focus on the here and now inter- action between client and worker.
18 8 JOHN MATUSHIMA, D.S.W.
The "here and now" pragmatic emphasis is frequently pre- sented as opposed to the "there and then" focus of traditional treatment. The false dichotomy is another of the "straw men" that are berated by the avant-garde theorists as an alleged con- trast between the new and the old. The experienced practitioner knows that the current problem as perceived by the client must be the center of mutual attention if the latter is truly to retain positive emotional involvement in treatment.
In those instances where the worker sees evidence of uncon- scious material that should be engaged, the client's own ego exerts control as to whether or not to allow the content to come to conscious awareness. As the ego's defenses against anxiety may be unable to allow conflictual material to consciousness even in the safest of circumstances, there is no chance for it to emerge if the worker continually bypasses the presenting problem for the "real genesis" as a matter of routine.
In any case, enduring internal conflicts as well as character traits soon manifest themselves within the client-worker relation- ship. Thus, where interactional problems involving, say, the client and significant-others is the treatment focus, inevitably such conflicts will be experienced by the client in current relation to the worker. In this sense, the past is a part of the present. And, while the client and worker may feel surprise and chagrin that an old-fashioned notion such as transference actually exists, the former may be helped to recognize its current manifestations if the latter tactfully waits until the evidences are clear and pertinent to the present problem. Again, to the extent that the client's own vacillating balance toward change is supported (rather than initiated) by the worker, the admissibility of further joint observa- tions linking cause and effect, past and present, is enhanced.
Whether one refers to learning theory, or the notion of un- mastered conflicts needing to be repeated by substituting situa- tions and characters until mastery occurs, it seems completely illogical to insist that each experience and sensation is discrete, to this moment, and is in no way related to previous pleasures and conflicts. The opposite would be just as fallacious, however, i.e., the insistence that the present is significant only as it repeats the past, or that no problem is resolved unless one grasps all of its unconscious antecedents. Pointless doctrinaire disputes about this matter might be avoided by attending to the evidence avail- able through prolonged and concentrated practice; such polarities are not found in actuality. Social work still "begins where the
PRACTICE-'
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well as character t-worker relation- ng, say, the client
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PRACTICE-THEORY TREE 18 9
client is," although restoration as well as support of effective social functioning remains a goal-and past, if necessary, is legit- i mate treatment territory as it relates to the "here and now."
Primacy of Client Accountability Principle: The client at all times consequences of his behavior.
The principle of client responsibility for his own behavior came into vogue in recent years as if it were a revolutionary departure from established treatment theory. This development is puzzling unless one assumes that the opposite view characterized treatment prior to the advent of reality therapy, i.e., that one was enslaved by one's problems, was helplessly overwhelmed by the power of the conflicts, or that mental illness excused anti-social acts. If such a view did have prominence in the mind of the lay public, it has not been representative of sound social work practice since its beginnings.
The importance of being non judgmental has been stressed, of course, and this interviewing principle may have been misinter- preted as absolving the client of all responsibility for the conse- quences of his behavior. Aside from being potentially destructive to others and approving violations of the most basic social com- pacts, such a stance would undermine the foundation of ego psychologically based treatment. The worker always gives support to the client's capacity to judge, plan, and implement those emo- tional and behavioral gratifications that are consonant with the client's and others' interests. Where choices must be made be- tween alternatives, the aim is to foster reality based decisions with full accountability as to their potential results.
The treatment aim could involve a "freeing-up" of previously repressed energies, of course, where such investments signifi- cantly inhibited the client's capacities for finding gratification in keeping with his own standards and social acceptability. On the other hand, the worker's activity would be directed to support of the _ client's self-controlling or inhibiting capacities where these were lacking, e.g., potential injurious acts to self or others, illegal acts. Entirely apart from considerations of ethics, the treatment rationale is based on a recognition that persons need and want controls over impulsivity-using their own controls if possible, but i mposed from outside themselves if necessary. While the strength- ening of ego functions might not always be successful, the task is not enhanced by lending sanction to normlessness, passive de-
remains responsible for the
19 0 JOHN MATUSHIMA, D.S.W.
pendency, and/or antisocial acts. The worker must remain allied with the client's need for self-mastery and responsibility, not the other half of the ambivalence that appeals to helplessness and disintegration.
Most experienced practitioners have noted that continuance/ discontinuance in treatment is often related to the degree of activity and self-responsibility that is expected of the client. Where techniques, however well-intended, promote dependency, passiv- ity, and infantilism, the client may directly or indirectly bring about the termination of treatment.
Relevance of Systems Theory In this discussion of ego psychology as an integrating theory
reference for practice, we made no mention of family interaction and the acknowledged social interactional pressures toward an equilibrium. Displacement of individuals' problems to family members or peers is a social reality. The focus of treatment is partially determined in such instances by the worker's assessment of the bases for the client's difficulty, e.g., reactive in such a way that withdrawal of the interactional pressures would alleviate his difficulty, or internalized in such a way that the problems have developed their own intrapsychic momentum. In the latter in- stance, one might combine individual treatment with related counseling, or one might opt for family therapy. Whatever the choice, however, it would appear to be compatible with the ego psychological treatment perspective that has been described in this paper.
Neither did we mention the impact of the broader social environ- ment on individual problems, but that most certainly would need to be acknowledged as a part of total assessment. Where social- ization as a whole has long since been recognized, e.g., the parent- child relationship, the waves of impact generated by poverty, racism, sexism, etc., cannot help but be intertwined with intra- psychic functioning and personality development. Such recogni- tion, however, is not in any way antithetical to the practice theory base that we have been discussing. Rather, these factors have to do with the social environment in relation to which ego function- ing develops and matures. Admittedly, and contrary to the view of some theoreticians, our stance does not accept the extreme view that intrapsychic functioning is only reactive to family and social pressures, nor that resolution of those external factors would eliminate the need for individual treatment. Nor does the
recognition of coli personality imply t viate the reality of i
Our emphasis ret and we therefore c that appear to be in, We believe that the the major foundati( that, at the point o actual dichotomies i
Our contention i references and that girds the work of tualization on the b, connections and vari further building tow;
Hamilton, Gordon. 1951. York: Columbia Universit Hollis, Florence. 1964. C House.
Perlman, Helen Harris. Chicago: University of Ch Simon, Bernece K. 1970. , Social Casework, eds. Rc Turner, Francis J. (ed). 1 A pproaches. New York: T
[ A, D.S.W.
rain allied ty, not the ssness and
r ntinuance/ degree of
ient. Where icy, passiv- -ectly bring
.ting theory interaction toward an to family
.reatment is assessment
such a way alleviate his )blems have to latter in- Nith related thatever the vith the ego described in
cial environ- would need
there social- . , the parent-- by poverty.,
f with intra- uch recogni- actice theory ;tors have to -go function-
to the view the extreme
o family and ernal factors [Nor does the
PRACTICE-THEORY TREE
recognition of collective social injustices and their impact on personality imply that removal of those same factors would ob- viate the reality of intrapsychic problems requiring treatment.
Our emphasis remains the social functioning of the individual, and we therefore centered on discussion of treatment principles that appear to be most relevant to the supporting of the individual. We believe that the ego psychological base continues to providethe
major foundation for our shared treatment approaches, and that, at the point of application, differences are not founded onactual dichotomies in conceptualization.
Our contention is that ego psychology provides the central references and that appropriate application of its principles under- girds the work of most successful practitioners. Better concep- tualization on the basis of that work, especially with regard to its connections and variations with other proposed notions, is basic to further building toward a theory of individual treatment.
REFERENCES Hamilton, Gordon. 1951.
Theory and Practice of Social Case W ork. 2d ed. NewYork: Columbia University Press. Hollis, Florence. 1964.
Casework: A Psychosocial Therapy. New York: RandomHouse.
Perlman, Helen Harris. 1957. Social Casework: A Problem-Solving Process.Chicago: University of Chicago Press.
Simon, Bernece K. 1970. "Social Casework Theory: An Overview," in Theories ofSocial Casework, eds. Roberts and Nee. Chicago: University of Chicago Press.
Turner, Francis J. (ed). 1974. Social W ork Treatment: Interlocking TheoreticalA pproaches. New York: The Free Press.
