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Fam Proc 1:141-145, 1962

Discussion
JERRY OSTERWEIL, PH.D.a
aPsychologist, Student Health Service, University of Pennsylvania, Philadelphia, Pennsylvania.

It is one of the challenging and often frustrating consequences of conducting intensive treatment of schizophrenics that it leads more than any kind of therapeutic work to frequent self examination. It is no accident that the people working in this area were prominent among those who first became interested in such topics as "immediate experience," shared relationships, "parataxic distortion," and "communication problems." In keeping with this critical introspective spirit, this symposium rather than being an uncritical testimony as has so often characterized panels discussing new methods of treatment, focuses on the problematic aspects of family treatment. Dr. Framo, for example, has emphasized the basic need for a rationale in undertaking family treatmenta conception of one's theoretical model and goals for the treatment process. He has also properly acknowledged that family treatment is conspicuously lacking such a conceptual framework at present. Anyone who has tried to do this kind of treatment will readily understand why it has been difficult to arrive at a satisfactory conceptual scheme. The literature on family treatment has consisted largely of highly intuitive papers which have attempted to develop new concepts to describe the interplay of intra-psychic dynamics and family interactions. There are only a handful of major theoretical concepts or hypotheses that are primarily of a descriptive, clinical character although they may be suggestive of broad functional relationships. Wynne's concept of pseudomutuality, which has provided part of the background for all these papers, is the most comprehensive formulation thus far and I believe comes closest to providing a preliminary model for treatment. In reflecting on these papers it is necessary to have this concept clearly in mind. Wynne (1) describes the pseudomutual relationship in the family of schizophrenic patients as one in which there is a strong primary investment in maintaining a sense of relationship ... even though it may be illusory ... an absorption in fitting together ... even at the expense of a failure to differentiate their identities, achieve personal growth or attain rich satisfying relationships. There is, furthermore, and inability to acknowledge or work through real differences in interests or feelings or any sources of dissatisfaction that normally occur in any relationship. This concept like most of the thinking about family treatment is a complicated mixture of many different frames of reference, such as the role theory borrowing from the work of Talcott Parsons and his group, the interpersonal theory of the Sullivanian group, communication theory, Freudian psychodynamics, as well as the newer thought in psychoanalytic ego psychology, particularly Erickson's work on ego identity. It is still very difficult to systematically articulate the relationship between these various frames of reference, and the various authors often describe very similar phenomena from only slightly different vantage points. These papers have discussed some of the major issues one must face in any attempt to weld these wide-ranging theories into a more comprehensive frame of reference. In my discussion I will comment on the statements that some of the authors have made about a number of these basic issues. The first basic issue has to do with one's assumptions about the motivational basis of the etiology and course of the schizophrenic process. There seems to be substantial agreement in these papers that a "basic orienting attitude" in this work is that the family structure and interrelationships have a primary, even if not necessarily exclusive, importance in the etiology and maintenance of a schizophrenic reaction. There is a conviction that a symbiotic tie is originally fostered by the parents, particularly the mother, and that after this has been internalized by the child, this pseudomutual relationship is actively sought by the patients as well as some member of the family. There is also a belief that a particular child is usually selected for this role. The schizophrenic patient's ability to fit the sick role in the family though, may in some instances be entirely independent of his predisposition for pathology. In some of the middle class families we see it is the most talented child who may be so narcissistically invested by the parents that he is prevented from developing his own identity. Dr. Nagy has offered us an interesting way of describing how the patient is prevented from becoming more independent, with his concept of the "counterautonomous superego". Does he mean through this formulation to give priority to faulty superego development like Wexler (2) does, rather than to faulty ego development as stressed by Hartmann (3) and Eisler (4)? A second basic issue discussed in these papers is the possible goals for family treatment. There appears to be substantial agreement about the general goals of treatment although there is considerable uncertainty expressed about being able to maintain a consistent approach for implementing these goals or of having a clear criterion for the termination of treatment. The general goal appears to be to disrupt pseudomutualitythat is, to get the members of the family to differentiate themselves by reaching a clearer conception of who is feeling and doing what to whom. Because the schizophrenic has difficulty in relating transference feelings in individual treatment to his real family and because the family tries covertly but intensely to preserve the pathological relationship, family treatment tries to confront the entire family with the full meaning
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of its present day maneuvers with one another. Only as the family as a whole is able to differentiate their roles, can the schizophrenic gradually gain a sense of his own ego identity. Dr. Midlefort, in the pioneering book in this field, "The Family in Psychotherapy" (5), formulated goals that appear to be diametrically opposite to the ones I just stated. He seemed to have felt that any tie with a significant relative that is 'accepting and acceptable' to the patient can help to maintain the patient's tenuous ties to reality; the other authors in this symposium seem to be trying to weaken rather than strengthen the patient's symbiotic tie with his family. I would suspect that this difference exists because Dr. Midlefort was working with a very different patient population. It would seem that most of his schizophrenic patients were rural, lower class, non-verbal patients; whereas these therapists have selected patients for intensive family treatment who are middle class, urban, and highly verbal. This, of course, would make one wonder if families' role in the etiology of schizophrenia is generalizable beyond the middle class? If one thinks about the goals for the end point of treatment in particular, one wonders, along with Dr. Framo, whether it will ever be possible to set or achieve a reasonable therapeutic rather than primary investigatory goal for family treatment. If the etiology of schizophrenia is viewed as it is here in interactional language, then it seems inappropriate to think of improvement simply in terms of the primary patient getting better and another member of the family, as we so frequently see, becoming disturbed or having an acute psychosomatic attack because they are now being deprived of some vital pathological gratification. It would seem that the outcome would also have to be stated in terms of some interactional criteria of how the family functions as a whole, and this is a formidable undertaking indeed. These thoughts lead into a third basic issue discussedone's aspirations about the prospects of family treatment and the implications of this kind of treatment for our traditional thinking about therapeutic structure. When one reflects, as we just have, on the process and possible outcomes of family treatment, one begins to realize what an amibitious, if not well-nigh pollyannish, therapeutic program it is; provocative as it may be as an investigatory procedure. In the typical family, there is one adult frankly psychotic and two parents with, at the minimum, rigid and pervasive narcissistic fixations. The therapists are trying to change their interrelationships and possibly their intrapsychic structures as well, even though the treatment of any one of these individuals has ordinarily been regarded as highly resistant to even the most intensive forms of individual treatment. Are the dramatic changes that do occur in these families merely temporary exchanges of roles or can there eventually be more substantial gains because there is therapeutic leverage here that is simply not available in more traditional treatment structures? If there is such leverage, should family treatment be given wider application even on a non-research basis to the families of delinquents and neurotics as Ackerman (6) and others have done? Would all the writers agree with Dr. Framo that concurrent individual treatment of the patient and even the parents is eventually necessary? Is the therapist's reluctance to treat families or enter their homes based, as Dr. Friedman suggests, more on personal defensiveness, rather than objective considerations of effective therapeutic structure? These are some of the far reaching implications of this work. The point is that all these questions need empirical research and they cannot be resolved by simply citing venerable authorities in the literature. The basic question is what kinds of research approaches will help to answer these questions without simply citing anecdotal evidence pro and con. The final basic issues I would like to briefly comment on are the peculiar personal demands that family treatment places on the psychotherapist. The family of the schizophrenic patient does violence to our implicit attachment to 18th century liberal rationalism; that is, they challenge our need for explicit meaning, as well as our liberal optimism about the strength of inherent growth motives, the salutory effects of benign impartial intervention, the motivational basis of our need to help people, and the value of exclusively verbal statements and logical explanation. This is probably one reason why existentialism, phenomenology, and other forms of subjective philosophy have become so intimately related to thinking about schizophrenia. These families can confound our rational theories, dispel optimistic planfulness, and plunge us into what Dr. Leslie Farber (7) in a paper on therapeutic despair described as a lack of confirmation regarding our roles. We, therefore, need to have much more precise descriptions and much deeper understanding of the various defensive maneuvers these families use to maintain their primitive state of ego diffuseness and the dubious pleasures of narcissistic excitement. This could be the first step in classifying the variants of defense that enable these families to ignore emotionally some of the outrageous reality incidents that have been described in these papers. In this way our research observations of these families' concerted efforts to maintain semantic chaos and "affective vacuums" may eventually reduce the "pseudomutual stalemate" that they so effectively create.

REFERENCES
1. 2. Wynne, L. C., Ryckoff, I. M. and Hirsch, S. I., "Pseudomutuality in the Family Relations of Schizophrenics," Psychiatry., 21, 205-220, 1958. Wexler, M., "The Structural Problem in Schizophrenia: Therapeutic Implications," Int. J. Psychoanal., 32, 157-166, 1951.

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3. 4. 5. 6. 7.

Hartman, H., "Contribution to the Metapsychology of Schizophrenia," Psychoanal. Study of the Child, 8, 177-198, 1954. Eissler, K. R., "Notes Upon the Ego Structure in Schizophrenia," Int. J. Psychoanal., 35, 141-146, 1954. Midelfort, C. P., The Family in Psychotherapy New York, McGraw Hill, 1957. Ackerman, N., Psychodynamics of Family Life, New York, Basic Books, 1958. Farber, L. H., "The Therapeutic Despair," Psychiatry., 21, 7-20, 1958.