a referral “bridge” for extended counseling

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Page 1: A REFERRAL “BRIDGE” FOR EXTENDED COUNSELING

A REFERRAL “BRIDGE” FOR EXTENDED

Maurice Rapkin, Ph. D. Director, Los Angeles Psychological Service Center

In 1960, during a joint discussion of the prob- lems in making referrals from the Conciliation Court to a private nonprofit agency, one of the evident problems was how to help the couples make the trans- fer from the “short-term” professional help that was available a t the Court to the “extended” help avail- able a t the Center. Four main difficulties to this transfer that may be mentioned ore:

COUNSELING

1. T h e g o d personal relationship that the couple develops with the referring counselor;

2. The absence of realist ic knowledge about the counseling and/or therapy Process, in sp i t e of the referring coun- selor’s interpretation of this process a t .the time of referral;

3. The economic cost; 4. The personal dynamics of the spouses.

This communication is a discussion of the methods jointly developed t o es tabl ish a referral “Bridge” to facil i tate this transfer.

The Court, at no fee to the applicant, provides a limited number of hours of professional help. Typ- ically, the husband and wife a re seen in one t o three conciliation conferences, each of which is really four separate interviews. The parties are first s een to- gethe: for a brief period, then separately, and together again for an extended three-way conference. Each conciliation conference takes about two hours. In this time, the Court Counselor attempts to orient the couple to an understanding and acceptance of a pro- gram which will help each spouse to achieve a better understanding of self , D greater sensit ivity to the spouse’s needs and a n approach t o improving the mar- riage relatioil ship. Couples who seek or accept refer- ral to the Court may have tried many ways t o find help for their marriage before they appear in the Coun- selor’s office. About seven out of ten families, how- ever, have not sought prior professional help. Surpris- ingly, many couples are able to make u s e of the one to three conferences t o re-establish a marital equili- brium without further help from the Court, whose counseling is “here-and-now reality oriented.” Others need ongoing assis tance since the personal and rela- tionship problems are deep-seated.

Before discussing the changes m a d e in our efforts to facil i tate this referral process, a brief de- scription of the background and usual procedures of t h e Center, and their contrast with. the changes made to establ ish the referral “Bridge”, may be helpful.

The Center w a s established in 1950 as a private, multidisciplinary group. The present staff includes Certified Psychologists, ACSIV Social Work- ers. Licensed Marriage Counselors, and a Psychiatrist. One of its basic policies was to provide psychologi- c a l services to that group of people whose income d i s q u d ified them for service by community-supported agencies, and yet was too small to be able lo afford private practice fees. A sliding fee s c a l e was devel- oped which took into account income, dependents, frequency of visit per week and other relevant finan- cial considerations. Usually, emotionally troubled people who applied for service were not functioning well in the economic area. By enabling them t o enter treatment a t the lower end of the s c a l e we found that they were able t o improve their earning ability. As their income increased, they were able to pay for more frequent consultations, when necessary. In this way, we established a financial bridge to intensive I

therapeutic help. Customarily, applicants for service are seen

first for intake. The intake worker presents her find- ings t o the staff where t h e case is discussed and a staff member (usually some one other than the intake worker) is selected as the regular therapist. While we feel that t h i s procedure h a s bas i c advantages, it h a s certain drawbacks - lor example, the negative feeling some people have abodt being shifted from one pro- fessional to another. The staff often recommended, especial ly in the init ial s t ages , that the applicant come for 2 or 3 v i s i t s per week.

Out of the experience of the Court making referrals and the Center receiving them, we jointly developed the following procedures intended to serve as a bridge.

We found, at the Center, that despi te the fact that the referring Counselor had briefed the couple on Center procedures. many of the couples had hazy or mistaken ideas about the procedures. It became clear that in the emotionally charged se s s ions with the Court Counselor, that “facts” about the Center’s location, procedures, etc-, were not attended to or remembered by the couple. Both agencies felt :hat a brief printed brochure which could be placed in the hands of the couple would help. T h i s brochure, among other things, made i t clear that while there was no organizational connection between the two agencies, they were cooperating for the couple’s benefit.

We 8lSO changed the intake procedure. Instead of each spouse being seen individually by separate intake workers once or twice, and then staffed for assignment to other counselors, we shifted to an “extended” intake procedure. Here, one counselor sees the couple jointly for the first s e s s ion (length- ened to one and a half hours). Then follows a se r i e s of s i x individual sessions. T h e usual frequency is

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Page 2: A REFERRAL “BRIDGE” FOR EXTENDED COUNSELING

once a week for each spouse . A t the initial s e s s i o n , the counselor and the couple try to arrive at mutually acceptab le goa ls and the procedures for reaching t h e s e goals. It i s made c l e a r t ha t there is n o promise of guarantee t o resolve all problems in the spec i f ied thirteen s e s s i o n s , but tha t through t h e s e s e s s i o n s , t he spouses will hopefully obtain a better grasp of their problems and the cho ices which a re open to them. I t should be noted tha t t h e idea of thirteen ses- s ions was sugges ted by the Court. T h e rationale w a s that families in a crisis qould more readily accept the idea of a referral if i t were presented on a “here acd now” b a s i s s i n c e thirteen s e s s i o n s represent on!y s i x to s e v e n weeks. A t t he time of referral, t he Court Counselor also reinforces the idea that thirteen s e s s i o n s will not necessar i ly s o l v e a l l t he problems, but by the thirteenth se s s ion , each partner i n the mar- riage would be in a be t te r position to eva lua te cho ices open t o them which might include the choice of con- tinuing beyond thirteen se s s ions . T h e formula of one conjoint s e s s i o n followed by s i x individual s e s s i o m may be modified to s u i t the needs of the couple. T h e counselor may feel that i t would b e bes t to continue with the joint s e s s i o n s to enab le both s p o u s e s to feel they a re working together on so lv ing their marriage problems. T h i s mutual focus on the marriage is often less threatening and less resistance-provoking than the individual s e s s ions . Or the counselor may feel that it is necessa ry tha t e a c h spouse have h i s own Counselor ( a s in a case of in t ense rivalry and/or jealonsy between t h e spouses) . In practice, we keep our approach flexible, incorporating the recent de- velopments in conjoint and family therapy.

In the individual s e s s i o n s , the individualized counseling t akes place. Near the end of the series, the spouses explore with the counselor whether there i s need for additional coirnseling or psychotherapy, for one or both spouses . They a r e now in a somewhat better p o s i t i ~ n to make t h i s dec is ion which must in- clude B knowledge of the helping process. Also, a t th i s point, the possibil i ty of their s ee ing another

. therepist or counselor may be explored. Typically, the original counselor cont inues to work with t h e couple.

In keeping with t h e “Bridge,” we modified our fcc policy. In the brochure given to the couple by the Court Counselor, it is s t a t ed that a flat. fee of $10 per s e s s ion ( e scep t the f i r s t one atid a half hour ses- sion which i s S20) will be charged. Thus, a total charge for thirteen s e s s i o n s is S140. Then if t he couple wishes additional help, they will b e billed at the regu!ar Center sl iding-fee-scale rates. T h i s spe - c i f ic fixed “package” is intended to help overcome feelings that counseling can go on indefinitely and that the cost is endless. By placing before them a known fee for a specified trial period, they may be more eas i ly ab le t o make the dec is ion t o accept t h e referral. Concurrently. we ind ica te that at t he end of the trial period, they will again makc a choice to con- t inue or discontinue.

Communication between the referring Coun- se lo r and t h e Center Counselor often plays a crucial part. Certain of t h e s p o u s e s may be described as 66 blame-oriented” and “action-oriented” people. Having left the Court Counselor with a posit ive halo, they may encounter some negat ive feelings toward the Center Counselor. Rather than d i s c u s s t h e s e negative feelings with the Center Counselor, they may choose to c a l l the Court Counselor in order t o complain. T h e Court Counselor h a s the opportunity t o reinterpret t h e counse l ing process to the spouse who then may b e sufficiently reassured to d i s c u s s h i s negative feel- ings with the Center Counselor. T h e posit ive feelings of the s p o u s e s for t he referring Counselor, which originally may make referral difficult, are here turned to the spouses’ advantage. Also, the good working relationship between the Court and Center Counsel- o r s makes it poss ib le to encourage the “action- oriented” to abandon their usua 1 manipulative coping methods in favor of facing the sou rces of their anxi- e ty within themselves. T h i s kind of counselor-in- depth relationship i s not usua l ly ava i lab le to t he self-referred patient, or to the one referred by an attorney or a general medical practitioner, or other professional sources.

T h e following case presentation may il lus- t ra te how the “Bridge” operates. Some of the de t a i l s a r e changed t o maintain the anonymity of the couple.

T h e wife had init iated divorce proceedings after 15 yea r s of marriage. T h e husband willingly and the wife reluctantly accepted referral to the Concilia- tion Service. Both s p o u s e s felt that they each had made many s i n c e r e e f for t s t o s u s t a i n the marriage, but that t he other had been unfaithful, uncommunica- t ive , arid uncooperative. T h e wife, in particular, felt tha t s h e had exhaus ted the poss ib i l i t i es of profes- s iona l help. She had obtained counseling a t 8 c l in ic in connection with her e lde r daughter, age 11, who was hard of hearing. Afterward. she had s c c n a thera- p i s t privately. When t h e therapist 18sided” with her aga ins t her husband’s extramarital affairs, and recom- mended a divorce, s h e broke off therapy. But a year later, s h e reluctantly init iated t h e divorce action. In talking to the Court Counselor, the wife was initially despa i r ing of making the marriage work. As the coun- se l ing progressed, the Counselor brought ou t that s h e must have a strong underlying wish t o sus t a in the marriage, as evidenced by her breaking off therapy when a divorce u a s recommended, and her will ingness to accept iurrher professional he lp desp i te the pre- vious failures. She a l s o seemed to be influenced by her husband’s will ingness t o get professional help. licr a t t i tude toward a referral to the Center seemed positive. She acknowledged the Counselor’s observation.

T h e husband, who seemed to be looking for a magical cure (i.e., h i s was a more surface optimism covering a n underlying feeling that nothing h e could do, would help,) was more reluctant to accept refer- ral. The Court Counselor gave them a copy of the brocliure. F i v e weeks later, the husband ca l led for an appointment. It developed that they had “misplaced” the brochure end h e didn’t think of ca l l ing the Court

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Page 3: A REFERRAL “BRIDGE” FOR EXTENDED COUNSELING

Counselor. It was only when the brochure “accident- ally” turned up tha t h e made the call to t h e Center.

In exploring their background,. the Center Counselor found that they had married in their t e e n s to e s c a p e a n unhappy home situation. Various reality hardships and trauma from their ear ly n,arriage had a cumulative stressfl i l effect. For example, the husband &*.as shipped o v e r s e a s while the wife w a s pregnant with their f irst baby. She fe l t very much a lone during t h e later months of her pregnancy. T h e baby boy ac- cideritally drowned when h e w a s four months old. T h e second child, a girl, was congenitally deaf. T h e third child, a boy, w a s brain-damaged and retarded. Severe marital quarrels began after they decided to p lace the third child in a s t a t e hospi ta l and the second child in a school away from home. Both began to “live it up” outside t h e marriage. A s the counseling progressed, their difficulty in communication and inabili ty to com- fort each other seemed related to the fact tha t neither had made a resolution of the i r grief and guilt over t h e placement of the youngest child.

In the fourth se s s ion , the wife’s guilt over the death of t h e first child, caused her t o misinterpret t he Counselor’s a t t i tude as crit ical of her. She pro- ceeded to phone the referring Counselor and with an “I told you so” att i tude, reminded him that s h e had sa id counseling would not work and that s h e planned to sto:, further counse l ing and go ahead with t h e divoice. T h e Court Counselor a sked whether s h e had d iscussed th i s with t h e Center Counselor, and when she said, “No” , he raised t h e possibil i ty that t h e wife had misunderstood, o r t ha t poss ib ly something e k e might be involved. H e asked whether anything posit ive had come out of the counseling and s h e s a i d that both she and her husband felt thev were better ab le to ta lk about feelings to each other: a l so , tha t they were a b l e to resume s e x relations. When the Court Counselor a sked whether s h e had d i scussed he r intentions to s top counseling with the Center Coun- selor, s h e sa id s h e had not. H e sugges ted tha t t h i s

.might be a good thing to do before going ahead with her plans. She had sufficient strength end confidence

in him to resume her counseling se s s ions . In con- fronting her Counselor, s h e tapped some of her own self-criticism and became very depressed. By the s ix th s e s s i o n , s h e recognized her need for further he lp and w a s eage r to cont icue with a more intensive program. She w a s still not sure that the marriage would work out, but s h e felt tha t un le s s s h e came to grips with some of the underlying issues in herself, s h e would never know.

The husband, in the initial stages, w a s less insightful. His reaction t o the counseling was more superficial . He was ab le to communicate better with h i s wife both verbally and physically. H e s t i l l looked for the rapid cure. In h i s fifth s e s s i o n , h e expressed a mild disappointment a t h i s wife’s dec is ion to ter- minate the counse l ing “so soon.” He had hoped that they would each go the full s ix s e s s i o n s , s i n c e they had gotten so much so far. With the wife’s dramatic turn-around, his underlying res i s tance to significant self-expression and exploration became more evident. His in i t ia l objection to continuing w a s the cost. Hi s wife countered by say ing that s h e would go to work part time, and with her earn ings , pay not only for her two times a week therapy, bu t for h i s one time B week. H e reluctantly agreed to continue. It w a s only la te r that h e w a s ab le t o ge t to h i s grief over the place- ment of the third child, and to the emotional trauma of h i s own childhood.

This case highlights cer ta in aspects of the “Bridge.” F i rs t . there w a s t h e Court Counselor’s recognition of t h e healthy s t r iv ings of the couple to work out t h e marriage. Then t h e Court Counselor “backing up” t h e Center Counselor, which helped t h e wife face difficult i s s u e s that s h e had turned away from in previous therapeutic attempts. T h e thirteen counse l ing s e s s i o n s seemed t o provide sufficient time for both husband and wife to make the transition to more in tens ive therapy. The package of thirteen sessions at a specified c o s t , appeared to make it e a s i e r for the husband to accep t the init ial referral to the Center. T h e s e sessions also gave them t i m e to work out their a t t i tudes toward continuing at a higher weekly cost.

Yir itors

Mr. W. Cadman Prout, Friend of the Court, Sixth Judic ia l Circuit of Michigan, County of Oakland, Pont iac , Michigan, and Mr. Danie l T. Murphy. Chair- man of t h e Board of Auditors, v i s i ted the Los Angeles County Conciliation Court on May 21 and May 22. The purpose of t h e visit w a s to s e e k a s s i s t a n c e in t h e es tab l i shment of a conciliation department i n Oakland County, Michigan.

In November, 1963, HonorabIe Arthur E. Moore, Circuit Judge, Pont iac , hlichigan, v i s i ted Los An- geles to study conciliation procedures, and the v is i t of Mt. Prout w d Mr. Murphy w a s another s t e p in the direction of ec tua l ly se t t i ng up a Conciliation Court program in Oakland County, Michigan.